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Pacemakers in the Elderly: A Review of Their Use



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Am Fam Physician. 2000 Feb 1;61(3):805-808.

Indications for implantation of a permanent pacemaker in the elderly are generally based on symptoms, the presence of heart disease and the presence of symptomatic bradyarrhythmias. Pacemakers for tachyarrhythmias, cardioversion and defibrillation are also available. Gregoratos reviews current indications for pacemaker use and advances in technology.

Patients more than 70 years of age account for greater than 70 percent of pacemakers implanted, in part. This is due to the physiologic changes that occur with aging, in which the heart's conduction system becomes disordered. Specifically, there is a reduction in P cells and an increase in collagen in the sinoatrial node. The number of conduction cells in the bundle of His and in the bundle branches also decrease. Hemodynamic compromise is more common in the elderly when these physiologic changes cause arrhythmias. The American College of Cardiology/American Heart Association recently issued practice guidelines outlining the indications for permanent pacing (see the accompanying table on guidelines). One of the main tenets is that symptoms need to be correlated with the arrhythmia before pacing is initiated. Many types of pacemakers are available, generally categorized by a three- to five-letter code according to the site of the pacing electrode and the mode of pacing. For a listing of generic pacemaker codes, see the accompanying table on codes.

Indications for Permanent Pacing in Acquired Atrioventricular Block in Adults

Class I

1. Third-degree AV block at any anatomic level associated with any one of the following conditions:

a. Bradycardia with symptoms presumed to be due to AV block

b. Arrhythmias and other medical conditions that require drugs that result in symptomatic bradycardia

c. Documented periods of asystole (≥3 seconds or any escape rate < 40 bpm) in awake, symptom-free patients

d. After catheter ablation of the AV junction; there are no trials to assess outcome without pacing, and pacing is virtually always planned in this situation unless the operative procedure is AV junction modification

e. Postoperative AV block that is not expected to resolve

f. Neuromuscular diseases with AV block such as myotonic muscular dystrophy, Kearns-Sayre syndrome, Erb's dystrophy (limb-girdle) and peroneal muscular atrophy.

2. Second-degree AV block regardless of type or site of block, with associated symptomatic bradycardia

Class IIa

1. Asymptomatic third-degree AV block at any anatomic site with average awake ventricular rates of 40 bpm or faster

2. Asymptomatic type II second-degree AV block

3. Asymptomatic type I second-degree AV block at intra- or infra-His levels found incidentally at electrophysiologic study for other indications

4. First-degree AV block with symptoms of pacemaker syndrome and documented alleviation of symptoms with temporary AV pacing

Class IIb

1. Marked first-degree AV block (> 0.3 second) in patients with LV dysfunction and symptoms of congestive heart failure in whom a shorter AV interval results in hemodynamic improvement, presumably by decreasing left atrial filling pressure

Class III

1. Asymptomatic first-degree AV block

2. Asymptomatic type I second-degree AV block at the supra-His (AV node) level or not known to be intra- or infra-Hisian

3. AV block expected to resolve and unlikely to recur (e.g., drug toxicity, Lyme disease)


AV = atrioventricular; bpm = beats per minute; LV = left ventricular.

Adapted with permission from Gregoratos G, Cheitlin MD, Conill A, et al. ACC/AHA guidelines for implantation of cardiac pacemakers and antiarrhythmia devices: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Pacemaker Implantation). J Am Coll Cardiol 1998;31:1175–1209.

Indications for Permanent Pacing in Acquired Atrioventricular Block in Adults

View Table

Indications for Permanent Pacing in Acquired Atrioventricular Block in Adults

Class I

1. Third-degree AV block at any anatomic level associated with any one of the following conditions:

a. Bradycardia with symptoms presumed to be due to AV block

b. Arrhythmias and other medical conditions that require drugs that result in symptomatic bradycardia

c. Documented periods of asystole (≥3 seconds or any escape rate < 40 bpm) in awake, symptom-free patients

d. After catheter ablation of the AV junction; there are no trials to assess outcome without pacing, and pacing is virtually always planned in this situation unless the operative procedure is AV junction modification

e. Postoperative AV block that is not expected to resolve

f. Neuromuscular diseases with AV block such as myotonic muscular dystrophy, Kearns-Sayre syndrome, Erb's dystrophy (limb-girdle) and peroneal muscular atrophy.

2. Second-degree AV block regardless of type or site of block, with associated symptomatic bradycardia

Class IIa

1. Asymptomatic third-degree AV block at any anatomic site with average awake ventricular rates of 40 bpm or faster

2. Asymptomatic type II second-degree AV block

3. Asymptomatic type I second-degree AV block at intra- or infra-His levels found incidentally at electrophysiologic study for other indications

4. First-degree AV block with symptoms of pacemaker syndrome and documented alleviation of symptoms with temporary AV pacing

Class IIb

1. Marked first-degree AV block (> 0.3 second) in patients with LV dysfunction and symptoms of congestive heart failure in whom a shorter AV interval results in hemodynamic improvement, presumably by decreasing left atrial filling pressure

Class III

1. Asymptomatic first-degree AV block

2. Asymptomatic type I second-degree AV block at the supra-His (AV node) level or not known to be intra- or infra-Hisian

3. AV block expected to resolve and unlikely to recur (e.g., drug toxicity, Lyme disease)


AV = atrioventricular; bpm = beats per minute; LV = left ventricular.

Adapted with permission from Gregoratos G, Cheitlin MD, Conill A, et al. ACC/AHA guidelines for implantation of cardiac pacemakers and antiarrhythmia devices: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Pacemaker Implantation). J Am Coll Cardiol 1998;31:1175–1209.

Generic Pacemaker Codes

Position 1 (chamber paced) Position 2 (chamber sensed) Position 3 (response to sensing) Position 4 (programmable functions; rate modulation) Position 5 (antitachyarrhythmia functions)

V—ventricle

V—ventricle

T—triggered

P—programmable rate and/or output

P—pacing (antitachyarrhythmia)

A—atrium

A—atrium

I—inhibited

M—multiprogrammability of rate, output, sensitivity, etc.

S—shock

D—dual (A & V)

D—dual (A & V)

D—dual (T & I)

C—communicating (telemetry)

D—dual (P + S)

O—none

O—none

O—none

R—rate modulation

O—none

O—none


Reprinted with permission from Bernstein AD, Camm AJ, Fletcher RD, et al. The NASPE/BPEG generic pacemaker code for antibradyarrhythmia and adaptive-rate pacing and antitachyarrhythmia devices. PACE 1987;10:794–9.

Generic Pacemaker Codes

View Table

Generic Pacemaker Codes

Position 1 (chamber paced) Position 2 (chamber sensed) Position 3 (response to sensing) Position 4 (programmable functions; rate modulation) Position 5 (antitachyarrhythmia functions)

V—ventricle

V—ventricle

T—triggered

P—programmable rate and/or output

P—pacing (antitachyarrhythmia)

A—atrium

A—atrium

I—inhibited

M—multiprogrammability of rate, output, sensitivity, etc.

S—shock

D—dual (A & V)

D—dual (A & V)

D—dual (T & I)

C—communicating (telemetry)

D—dual (P + S)

O—none

O—none

O—none

R—rate modulation

O—none

O—none


Reprinted with permission from Bernstein AD, Camm AJ, Fletcher RD, et al. The NASPE/BPEG generic pacemaker code for antibradyarrhythmia and adaptive-rate pacing and antitachyarrhythmia devices. PACE 1987;10:794–9.

First-degree atrioventricular (AV) block, thought to be a relatively benign arrhythmia, can be associated with severe symptoms that may benefit from permanent pacing. Specifically, some uncontrolled trials have shown a benefit from pacing in patients with a PR interval greater than 0.3 seconds. Type I second-degree AV block does not usually require permanent pacing because progression to a higher degree AV block is not common. Permanent pacing is known to improve survival in patients with complete heart block, especially if they have had syncope.

Permanent pacing is not needed in a number of conditions, even in patients with advanced AV block. Reversible causes of AV block, such as electrolyte disturbances or Lyme disease, simply require treatment of the underlying cause. In other situations, AV block occurs only sporadically, as with sarcoidosis, but should be treated with pacing because of the known history of disease progression. Implantation is typically easier and of lower cost with single-chamber ventricular demand (VVI) pacemakers, but use of these devices is becoming less common with the advent of dual-chamber demand (DDD) pacemakers. Symptoms of AV block generally resolve after insertion of a DDD pacemaker, although the prognosis is poorer in patients with severe left ventricular dysfunction and coronary heart disease.

Sick sinus syndrome (or sinus node dysfunction) is the most common reason for permanent pacing. For an algorithm describing selection of pacemaker type in these patients, see the accompanying figure. Symptoms are related to the bradyarrhythmias of sick sinus syndrome, and they direct the decision to initiate permanent pacing. VVI mode is typically used in patients with sick sinus syndrome, but recent studies have shown that DDD pacing improves morbidity, mortality and quality of life. Some newer pacemakers allow automatic switching from DDD to VVI, so that episodes of atrial tachycardia are not tracked by the ventricles.

The author concludes that careful assessment of symptoms, analysis of the arrhythmia and selection of appropriate pacemaker type may lead to improved outcomes in some elderly patients.

FIGURE.

Selection of pacemaker systems for patients with sinus node dysfunction. (AV = atrioventricular)

Ada pted with permission from Gregoratos G, Cheitlin MD, Conill A, et al. ACC/AHA guidelines for implantation of cardiac pacemakers and antiarrhythmia devices: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Pacemaker Implantation). J Am Coll Cardiol 1998;31:1175–1209.

View Large


FIGURE.

Selection of pacemaker systems for patients with sinus node dysfunction. (AV = atrioventricular)

Ada pted with permission from Gregoratos G, Cheitlin MD, Conill A, et al. ACC/AHA guidelines for implantation of cardiac pacemakers and antiarrhythmia devices: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Pacemaker Implantation). J Am Coll Cardiol 1998;31:1175–1209.


FIGURE.

Selection of pacemaker systems for patients with sinus node dysfunction. (AV = atrioventricular)

Ada pted with permission from Gregoratos G, Cheitlin MD, Conill A, et al. ACC/AHA guidelines for implantation of cardiac pacemakers and antiarrhythmia devices: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Pacemaker Implantation). J Am Coll Cardiol 1998;31:1175–1209.

Gregoratos G. Permanent pacemakers in older persons. J Am Geriatr Soc. September 1999;47:1125–35.



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