Author Topic: Atrial Fibrillation and Heart Rate Monitoring Help?  (Read 1204 times)

Atrial Fibrillation and Heart Rate Monitoring Help?
« on: August 26, 2019, 11:45:40 am »
A few weeks ago a had a TIA (mini-stroke) while ordering coffee in the middle of a bike ride.  I recognised the signs, though I have not had one before and rode home (having finished my coffee) and later that day went to hospital to have it confirmed.  After several appoinments and a battery of tests, some of which are yet to be analysed, I have been diagnosed with atrial fibrillation and it has been discovered that I have a severely ineffiecient heart with an ejection fraction of possibly lower than 30%.  I was prescribed statins and edoxoban (anticoagulant) and I am taking these, despite reservations, until all the ends are pulled together and I can have a better consultation with a specialist (I am waiting for the results of a brain scan to decide which type of stroke I had) and from a 5-day heart rate monitor test (R Test).
This has all come as a terrific shock and disappointment after 73 years of almost complete good health.  I have no risk factors (except age):  I am fit, have a healthy diet, don't smoke, hardly drink and all my blood results are satisfactory and I haven't got significantly high cholesterol.
The specialist said (on being asked) that I was fine to continue exercising at the rate I do.  But when  I had an echocardiogram a week later, which discovered the low ejection fraction, thre technician suggested it might be a good idea to "take it easy".  That's what I'm doing, because I don't mind admitting that I am mildly frightened by this turn of events.

I've taken my blood pressure and pulse for years, using a machine such as is used in hospital (OMRON) and have always had low (not dangerously) blood pressure, which was confirmed in hospital.  This BP monitor continues to show my pulse in the 60 -70 range.  But the hospital has me at 90 + variable.  I got a heart-rate monitor, too, now, and that shows my resting heart at about 110 but has me at over 150, if I so much as walk to the shop.  I did a very gentle bike ride and it was in the 180s, when I was hardly going faster than required to keep the bike moving.  In my usual exercise mode I would be technical dead, I imagine.

I feel NO symptoms and never have.  No breathlessness, stiffness, NOTHING.  I understand this is quite common.  I also had a MRI scan on my heart 3 years ago (after a lightheaded episode) and it showed no abnormalities although a treadmill test showed I have ectopics (and I nearly bust the machine!).

It occurred to me that as the heart-rate monitor shows 40bpm above the BP monitor, I guess it is picking up the fibrillation while the BP monitor, which is on the arm only picks up the underlying beat - is that possible?  That makes me wonder whether or not I'm alarming myself unnecessarily about the HRM readings, which if I knock 40 off are not so bad?  What does the team think?

I'll say now that I'm not going to act on the above until I have a chance to talk properly to a specialist.  I'm going to go on taking it easy!

I know how to trawl the net; but I wondered if anyone here has personal experience.


Sorry to go on but after years of loving my exercise, I'm not only frightened about my health but very frustrated!

Thnk you

Peter

Kim

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Re: Atrial Fibrillation and Heart Rate Monitoring Help?
« Reply #1 on: August 26, 2019, 11:58:04 am »
It occurred to me that as the heart-rate monitor shows 40bpm above the BP monitor, I guess it is picking up the fibrillation while the BP monitor, which is on the arm only picks up the underlying beat - is that possible?

Sounds entirely plausible.  The HRM (assuming an electrical chest strap sensor type) will have been designed for a normal rhythm[1], and all bets are off if your heart's doing something electrically weird.  It's not like a diagnostic ECG machine where making sense of abnormal rhythms will have been part of the design spec.


[1] In an "adjust the gain for the strongest part of the waveform and count the pulses" sort of way, rather than knowing anything about hearts.
To ride the Windcheetah, first, you must embrace the cantilever...

Re: Atrial Fibrillation and Heart Rate Monitoring Help?
« Reply #2 on: August 26, 2019, 12:04:17 pm »
Thank you, Kim!  I'm still going with taking it easy until more diagnosis has been done but I'm allowing myself to be relieved that my heart is probably not going to blow up!

Kim

  • Timelord
Re: Atrial Fibrillation and Heart Rate Monitoring Help?
« Reply #3 on: August 26, 2019, 12:14:49 pm »
Disclaimer: IANAD, but I did molish a rudimentary heart rate monitor (operating on the above principle) as a GSCE project many years ago.  It was pretty cool getting the cardiac waveform on the oscilloscope, but mostly it was an education in all the different ways that human beings can introduce noise into your circuit (simply moving around was enough to throw the counter reading off, it barely coped with the presence of mains electricity in the same room, and certainly wouldn't have handled an abnormal rhythm).  I'm constantly impressed by how well the Garmin things work, let alone hospital-grade kit[1].


[1] Yes, I'm the patient who confused recovery room nurses by stopping breathing while trying to work out how the monitor was deriving respiration rate[2].
[2] I looked it up when I got out of hospital: It measures the impedance of your chest cavity through the three-wire ECG pads.  Witchcraft!
To ride the Windcheetah, first, you must embrace the cantilever...

Basil

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Re: Atrial Fibrillation and Heart Rate Monitoring Help?
« Reply #4 on: August 26, 2019, 12:18:02 pm »
Agree with Kim.  When I first suffered from af, my cheap chest strap monitor was giving bmp of 300 +. Basically it couldn't interpret the samba rythmn of my heartbeat.
Quote from: Kim
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Re: Atrial Fibrillation and Heart Rate Monitoring Help?
« Reply #5 on: August 26, 2019, 12:29:28 pm »
 ;D  Mine's more Stravinsky than Samba, worse luck!

@ Kim  That's just typical of you: to be doing experiments whilst dying!  I actually don't breathe regularly at all.  I don't have anything wrong - I just don't bother to breathe.  I'm always accused of sighing, when it's just my body forcing me to breathe from time to time.

Re: Atrial Fibrillation and Heart Rate Monitoring Help?
« Reply #6 on: August 26, 2019, 01:44:49 pm »
What you are describing is the difference between pulse waveform picked up by the peripheral monitor and the electrical function of the heart where you are picking up the atria fibrillating at a significantly higher rate.  Fibrillation simply means spontaneous electrical activity in a muscle fibre not under nerve control.  If the nerves and conduction pathways in your heart are beating at X but the spontaneous rythm of the atria is 2X then your peripheral HRM will say a HR of X but a chest strap eg garmin will say a rate of 2X.  This is the essence of the new apple watch where there is an optical HRM in the base of the watch and if you touch the crown with the other hand it measures electrical.

If you have been like this for some time then you may very well have been functioning with a low ejection volume for quite some time as a result of the AF or you may have underlying ventricular cardiac disease.

This may be overly technical but seems a relevant article https://www.cfrjournal.com/articles/ablation-AF-HF-reduced

There is a professor in Liverpool/Chester who has a special interest in athletes and heart problems but try your local people first.  I would specifically ask them what treatment they would offer a 40 year old with the same problems, findings, etc and why apart from age are you not eligible.  We still suffer from significant ageism in this country.  You might also take in a list of your last 20 rides or so to confirm what you do and why you want to continue.

Re: Atrial Fibrillation and Heart Rate Monitoring Help?
« Reply #7 on: August 26, 2019, 02:37:31 pm »
I had an episode of AF at the age of 56 in July 2017 just before I was expecting to ride LEL. I noticed that I was very breathless whilst running at an easy pace and took 30 mins to recover instead of the usual 2-3 mins. After a further run with similar results and using a Polar HR monitor I called 111 and was advised to attend hospital urgently. After diagnosis I was put on anti-coagulant and beta blocker. Like yourself this came as a major shock and I initially found it very difficult to come to terms with after running and cycling for 20+ years. I only walked and took short, easy cycles for 3 months until I had a cardioversion. Fortunately this was successful and I have maintained normal sinus rhythm since then. I stopped the beta blocker on day of cardioversion and anti-coagulant approx 5 months later.

After the cardioversion I steadily built up exercise level/duration and used an HR monitor to keep intensity levels steady, limiting to 150 HR. I did see, and continue to see, the occasional spike up to 180-190 HR but it has always recovered within 5-10 seconds. I sometimes noticed an almost imperceptible flutter during these spikes and at other times was only aware of them on reviewing the HR recording. During 2018 I started to ride audax events again and completed an SR. I had meeting with private Electro-Physiologist in Sept 2018 and presented Polar records of the HR spikes. After a long discussion he encouraged me to keep exercising and be a little less focused on the HR monitor.

This year I have continued to run and cycle regularly. I don't push myself like I used to but can still do a respectable pace. On 400+ km rides I have noticed that on 2nd day my HR is very stable with no unusual spikes. At the beginning of the year my aim was another SR and maybe PBP. I completed both and really enjoyed PBP.

I aim to be caffeine free, have only the occasional beer, eat and sleep well and try to do the "right" things to keep AF at bay. I'm grateful for each day that I can continue to get out and exercise.

Wishing you a return to sinus rhythm and a good recovery. It is certainly possible.

T42

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Re: Atrial Fibrillation and Heart Rate Monitoring Help?
« Reply #8 on: August 26, 2019, 02:50:48 pm »
In my BP monitor the cuff connection is entirely pneumatic, so it can't possibly pick up A-fib.

Three or four of my cycling chums have started with it in the last few years, and I've a vague, totally uninformed, impression that it could well be due to a lifetime of driving one's heart at high frequencies.  A popular treatment here, too, seems to be catheter oblation: at least it's popular with the cardiologists, but the effect on the recipients seems to be rather hit and miss. In one case the 'beneficiary' can now barely cycle even with an eBike, while another is still doing Audaxes and has noticed no difference in power.  The cases in the middle are now on eBikes.

Re ageism, it's not just the UK.  There seem to be standard cocktails according to age - "he's over 70, give him beta-blockers (the cardiologists' sliding spanner) and anticoagulants". Oh, and if you fall off the bike be careful not to hit the ground.

In my own case I can relate instances of A-fib (well, the occasional strange zzz-zzz-zzz-thump sensations in the chest after hard rides) to caffeine intake and bloody-minded climbing, so next time I'm due at the cardiologist's I'll be off the bike and off the coffee for a week in advance.  Of course, the instances I notice might not be the only ones that occur...  I want my own Holter and a Cardiology 101 course.
I've dusted all those old bottles and set them up straight.

Re: Atrial Fibrillation and Heart Rate Monitoring Help?
« Reply #9 on: August 26, 2019, 03:37:42 pm »
Thanks, people - lots to consider, there, which I'll look at later.  Just been for a fibrillate in Morrisons, so am taking a break!

Peter

T42

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Re: Atrial Fibrillation and Heart Rate Monitoring Help?
« Reply #10 on: August 26, 2019, 04:21:39 pm »
I'd add that years ago I accompanied my FiL to an interview with an anaesthetist before one of his many operations (heart, spine, colon, aneurysm...), and when the anaesthetist asked in passing what kind of sport I did, and I told him, he went on to say with relish "Aha, we'll have you in for a pacemaker one of these days".  I do like people who enjoy their jobs.
I've dusted all those old bottles and set them up straight.

quixoticgeek

  • Mostly Harmless
Re: Atrial Fibrillation and Heart Rate Monitoring Help?
« Reply #11 on: August 26, 2019, 04:54:49 pm »

If you want an electronic device for monitoring your heart rate without having to pummel your arm with a BP monitor, consider one of the cheap pulse ox devices, you don't need the most expensive just to monitor your pulse. About 20 quid on amazon will get you something that will do the job (https://amzn.to/2ZjJTEX)

Being that it detects based on blood flow, the AF shouldn't mess with it.

J
--
Beer, bikes, and backpacking
http://b.42q.eu/

Re: Atrial Fibrillation and Heart Rate Monitoring Help?
« Reply #12 on: August 26, 2019, 05:38:44 pm »
In France we have an association called the Amicale des Cyclocardiacs (T42 might have come across them) which is a club for cyclists who have had heart trouble, attacks and the like. (One of my club members is quite active in it). Does the same sort of group exist in UK?
Disclaimer: IANAD, but I did molish a rudimentary heart rate monitor (operating on the above principle) as a GSCE project many years ago.  It was pretty cool getting the cardiac waveform on the oscilloscope, but mostly it was an education in all the different ways that human beings can introduce noise into your circuit (simply moving around was enough to throw the counter reading off, it barely coped with the presence of mains electricity in the same room, and certainly wouldn't have handled an abnormal rhythm).  I'm constantly impressed by how well the Garmin things work, let alone hospital-grade kit[1].


[1] Yes, I'm the patient who confused recovery room nurses by stopping breathing while trying to work out how the monitor was deriving respiration rate[2].
[2] I looked it up when I got out of hospital: It measures the impedance of your chest cavity through the three-wire ECG pads.  Witchcraft!

When I was in recovery they kept yelling at me to breathe when all I wanted to do was doze off the first time. The second time with a lighter dose of anaesthetic I was well awake but the nurses weren't happy until a very kind one looked and said "but the clip is on the wrong finger, I'll fix that. Oh and you're cold, lets get the heated blanket on you" after which things improved rapidly. After that a nurse came in who recognised me, saw the name on the form and said"but it's Laurence's husband:" at which it turned out that at least half the recovery room nurses had either worked with my wife or knew her from work contacts. They got me out quite quickly after that (that was all said in french of course)   

Re: Atrial Fibrillation and Heart Rate Monitoring Help?
« Reply #13 on: August 27, 2019, 08:35:48 am »
I would trust the Omron machine over a Garmin to get an accurate pulse - as you've suggested, it is likely the Garmin is picking up fibrillation (my partner gets this, it is quite frightening to hear/feel her heart going thrrrbbb instead of beating properly).

As for your pulse in hospital; that is just typical 'white coat syndrome'. Many people get raised blood pressure and pulse rates in hospitals.

Peter, I'm surprised to read all of this. Having ridden with you a couple of times, I know you are such a strong quick rider.
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Re: Atrial Fibrillation and Heart Rate Monitoring Help?
« Reply #14 on: August 27, 2019, 09:18:59 am »
In France we have an association called the Amicale des Cyclocardiacs (T42 might have come across them) which is a club for cyclists who have had heart trouble, attacks and the like. (One of my club members is quite active in it). Does the same sort of group exist in UK?
That's interesting. My situation is different; I had a (very mild indeed) heart attack in early June, leading to bypass surgery a week later. Unfortunately I had some complications (infection etc.) and only finally left hospital at the end of July. I'm currently banned from riding while my rib-cage recovers, but hoping to get back into it soon. In the meantime I'm wearing a Garmin wrist gadget and walking as much as possible - up to 40 miles a week.

Would be good to have a group where experience could be shared.

T42

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Re: Atrial Fibrillation and Heart Rate Monitoring Help?
« Reply #15 on: August 27, 2019, 09:32:13 am »
In France we have an association called the Amicale des Cyclocardiacs (T42 might have come across them) which is a club for cyclists who have had heart trouble, attacks and the like. (One of my club members is quite active in it). Does the same sort of group exist in UK?

Yes, I know a couple of riders who are in it but never wanted to join because while I don't avoid being aware I don't want to wallow in it. Anyway, my YACF jersey is much prettier than theirs.
I've dusted all those old bottles and set them up straight.

quixoticgeek

  • Mostly Harmless
Re: Atrial Fibrillation and Heart Rate Monitoring Help?
« Reply #16 on: August 27, 2019, 11:14:11 am »
As for your pulse in hospital; that is just typical 'white coat syndrome'. Many people get raised blood pressure and pulse rates in hospitals.

I have the complete opposite. My home auto BP machine thingy consistently reads high, yet when I went to my GP, both her, and the nurse have checked my BP, and it's fine. I've returned one BP machine, thinking it was faulty, but the replacement unit does exactly the same thing.

J
--
Beer, bikes, and backpacking
http://b.42q.eu/

Kim

  • Timelord
Re: Atrial Fibrillation and Heart Rate Monitoring Help?
« Reply #17 on: August 27, 2019, 09:56:40 pm »
I wonder if there's something about the way the BP machines work that makes them prone to reading high?

I've got a basic analogue dial sphyg at home with the nastiest stethoscope ever made (at least without the benefit of a Fisher Price logo), works fine.  The GP's electronic ones tend to over-read, and if they express concern I get them to do it again with the proper mercury manometer, which tends to be consistent with what I get at home.
To ride the Windcheetah, first, you must embrace the cantilever...

Re: Atrial Fibrillation and Heart Rate Monitoring Help?
« Reply #18 on: August 29, 2019, 11:23:41 am »
Hello again, Resus. Team!  Let's hope it turns out to be R(h)esus positive!

   Naturally, I've been giving your kind posts and the problem in general a fair amount of thought, in the hope of trying to crystallise what I need to ask the consultant, not that it is likely to be the same one, it rarely is.  Seeing the GP depends on having been walled in when the clinic was built.  But I have a telephone appointment booked, so I look forward to helping him with his problems.

   Thoughts as follow:-

AF is an electrical fault, for which there are two lines of treatment (according to mainstream medicine):-

1.  Invasive methods, such as ablation, cardioversion and pacemakers.  I don't know enough about ablation (although I have read your link, Chris, for which "thanks"!) but cardioversion may not be an option for me because I suspect my AF has not been sudden (would sudden AF cause a clot so quickly?).  I think a pace maker would not initially be used in my case because they are for atrial fibrillation where the base heart-rate (pulse) is too high anyway.  Beta blockers are used to bring the overall rate down and this often leads to the base rate being too low, so it is boosted by a pacemaker.

2. Medication.  I have been prescribed Atorvastatin, though I'm not sure why (my cholesterol is only just over 5 and the proportions are good (less than 2)).  I was told some time ago after a routine MOT that such a level was not considered a problem in someone with my healthy lifestyle.  Incidentally, my parameters have been collated to give CHAD2S2VASC of 3 and HAS-BLED of 1.  I only feature on the CHADS one by virtue of age and the fact that I have now had a TIA.  The HAS-BLED one is age only, I think.  These results posit a 3% chance of a further stroke.

(Chris, thank you for your mention of  heart disease as a cause.  There's certainly at least one poorly functioning  part( LV), for which the numbers don't look good -  and my mother died of heart failure.  I've also read that strenuous exercise can be a factor and it may be instructive that although I've always been fit, I only took up Audax in my mid 60s, after which I did about 150 rides, including a 600 and several very hilly 400s.  A significant factor may be that I did most of my riding on insufficient sleep, even the 200s, but I don't think I was ever "distressed"!  Odd that strenuous exercise doesn't feature in the CHAD2S2VASC list - I thought AF was well known to be a possibility for endurance athletes.)

The other drug I have been prescribed is Edoxaban, which is an anti-coagulant.  I'm a little surprised at this because when I was prescribed it, it was a month ago and I still haven't had the results of the MRI scan which is supposed to indicate whether or not I've had a bleed to the brain, or a clot.  I know the latter is very much more likely, although, mercifully the echocardiogram couldn't find any obvious evidence of a thrombus in the heart.  So I sort of understand the reasoning behind the anticoagulant, even ahead of the MRI results. 

   Both anticoagulants and statins have their downsides but the one I'm more concerned about is one I haven't been prescribed yet but might be when all the results are in.  Of course, I'm talking about beta blockers.  I have a basic heart-rate of about 55.  That has always been the case and was again today when I took the average of four readings, taken at 3 or 4 minute intervals after a three mile walk this evening (no symptoms, as usual).  These were on the BP monitor, by the way.  It seems to me that beta-blockers would just bring my "natural" heart rate down to a level at which I'll need a pace-maker.  I can still see a logic in that if it is actually the only way offered to me to get the AF reduced but I really don't want to go there!

   So, in summary:  it seems to me that in spite of the phraseology used in medical literature, drugs do not treat AF if you have an underlying low heart rate.  What they do is try to ameliorate the possible effects of AF, without actually removing it.  The likeliest way of "removing" AF is surgical intervention of some kind.  Or can it spontaneously disappear?  (Please only answer "yes" if you actually know!)

   I'm aware that AF is unlikely to kill of itself, and that related stroke is a much likelier danger than a heart attack.  But I also know that the heart is not intended to be pounded at AF levels and will probably weaken.  It's a bit of a conundrum!

@ Chris again:-  your suggestion to ask the consultant how they would treat a 40-year-old had already occurred to me.  It was nice to have it emphasised by you!

@ mrcharly:  A, thanks for your compliments!  I'm really surprised by what's happened, too.  I think it's the case that many, if not most, people who are diagnosed with A fib have no symptoms. 

I think the likeliest reason for my condition is exercise-induced AF (and possible heart damage), with a little genetic disposition thrown in.  Maybe Sleep Apnoea, too (I do occasionally wake up as though I've dropped down a lift shaft).  I'm still awaiting the results of my brain MRI and the R-Test .  The trick then will be to get the correct treatment for my case and/or learn to adjust to a different future, which I'm sure I can do - but I only want to do it if I have to!

Thank you all again.  Be happy - don't worry!

I'll keep you p.....aaaaaaagh...................!

Re: Atrial Fibrillation and Heart Rate Monitoring Help?
« Reply #19 on: August 29, 2019, 12:15:02 pm »
Quote
I have been prescribed Atorvastatin, though I'm not sure why
Statins are used as a drug for everybody with any heart problem as if you treat thousands of people with statins a few will have less heart disease even if cholesterol is normal.  You can perhaps guess my view of statins and most of my colleagues.

Quote
Edoxaban, which is an anti-coagulant
The aim of this is to stop clots forming on the inside wall of the atrium.  In AF as the flow is poor with loss of proper emptying you get stagnant blood clotting on the wall and then breaking off to cause the TIA.  The anticoagulant stops the clotting.

Quote
I have a basic heart-rate of about 55
I am not a cardiologist!!  However the percieved rate may be low because the AF is not filling the ventricle enough and there is not sufficient emptying to register.  The 55 may actually be a false low reading.  Your heart may want to pump faster but cannot.  If you feel your pulse you may find that the pulse is irregular with what seems like missed beats which if filled in would be more like 60-65.  Alternatively you may have some form of electrical conduction abnormality. I am sure helly knows more about this but a low pulse rate is relatively unusual in AF but not unknown

Goos luck


T42

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Re: Atrial Fibrillation and Heart Rate Monitoring Help?
« Reply #20 on: August 29, 2019, 01:20:02 pm »
Good luck from me too.

Without wanting to be alarmist, I'd want to be well-informed of how well pacemaker leads stand up to being flexed at 150 Hz before I consented to having one. There have been a couple of hundred thousand cases of leads having to be explanted following a recall for fracturing.
I've dusted all those old bottles and set them up straight.

quixoticgeek

  • Mostly Harmless
Re: Atrial Fibrillation and Heart Rate Monitoring Help?
« Reply #21 on: August 29, 2019, 01:20:39 pm »

Does anyone know if AF is hereditary?

J
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Re: Atrial Fibrillation and Heart Rate Monitoring Help?
« Reply #22 on: August 29, 2019, 02:21:14 pm »

Does anyone know if AF is hereditary?

J

I was told by my cardiologist that AF is not hereditary but that it does run in families (my mother, one of her two sisters and one of her three brothers all had / have AF as do I, though neither of my two siblings have it). I think I know what he meant, but if one of the YACF medics cares to elaborate that would be great.
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T42

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Re: Atrial Fibrillation and Heart Rate Monitoring Help?
« Reply #23 on: August 29, 2019, 03:31:49 pm »
From what little I have read, I gather that it's not uncommon in folk over 70.
I've dusted all those old bottles and set them up straight.

Re: Atrial Fibrillation and Heart Rate Monitoring Help?
« Reply #24 on: August 29, 2019, 03:46:39 pm »
It is impossible to be sure about the extent to which AF is inherited. There is a group of genes that are associated with an increased risk of AF in families, and it is thought that about 30% of cases of AF that do not have an identifiable cause may be familial.

It is difficult to isolate the genetic component. Many of the risk factors for AF themselves have degrees of heretibility. And many of the risk factors for AF "run in families" in that lifestyle factors are also often common among family members.

The majority of cases of AF are related to age, high blood pressure, and co-existing coronary artery disease. Going down the genetic rabbit hole is unproductive.

I have a basic heart-rate of about 55.  That has always been the case and was again today when I took the average of four readings, taken at 3 or 4 minute intervals after a three mile walk this evening (no symptoms, as usual).  These were on the BP monitor, by the way.

Ditch the monitoring devices and use the MkI finger and a watch. Is your pulse regular or irregular? Get familiar with how it feels so that you can identify change.

If your usual pulse rate (I take it by "basic" you mean at rest) was always 55 ish, and when you were in AF it was 90 - 150 odd depending what you were doing, and now it is steadily around 55 even when not on rate-limiting meds (I assume you are not yet on a beta blocker), one possibility is that you have reverted back to a normal rhythm.

However, even if the AF is intermittent (or paroxysmal), the same concerns, risks, and need for investigation apply, so stay on the edoxaban until you see a cardiologist.

Without wanting to be alarmist...

Pacemaker lead fractures occur at a rate of a few percent of implantations and the vast majority of fractures are due to overly vigorous upper limb movement or chest trauma.