eMedicine Specialties > Cardiology > Electrophysiology Procedures

Pacemaker Syndrome: Differential Diagnoses & Workup

Author: Daniel M Beyerbach, MD, PhD,, Consulting Staff, Florida Electrophysiology Associates; Affiliate Clinical Assistant Professor of Biomedical Science, Florida Atlantic University, Regional Campus of University of Miami Miller School of Medicine
Coauthor(s): Christopher Cadman, MD, Director of Arrhythmia Service, Assistant Professor, Department of Internal Medicine, Division of Cardiology, University of New Mexico
Contributor Information and Disclosures

Updated: Nov 13, 2009

Differential Diagnoses

Acute Coronary Syndromes
Pacemaker-Mediated Tachycardia
Carotid Sinus Hypersensitivity
Paroxysmal Supraventricular Tachycardia
Hyperthyroidism
Pulmonary Edema, Cardiogenic
Hypothyroidism
Pulmonary Embolism
Pacemaker Failure

Other Problems to Be Considered

Pacemaker malfunction
Inappropriate mode switching
Worsening heart failure, unrelated to pacemaker function
Recent change in medications, particularly antihypertensives
Paroxysmal atrial fibrillation
Dehydration
Neurocardiogenic syncope
Postural orthostatic hypotension syndrome
Inappropriate sinus tachycardia (common in young women survivors of childhood sex abuse)
Infection, particularly upper respiratory infection, pneumonia
Autonomic dysfunction
Adrenal insufficiency

Workup

Laboratory Studies

  • No lab studies are indicated.
  • Begin workup by performing pacemaker interrogation. Rule out excessive ventricular pacing, and look for evidence of AV dissociation or VA conduction. Also rule out pacemaker malfunction, end of battery life, mode reversion for energy conservation, and inappropriate mode switching.
  • The best method of diagnosis is to correlate patients' symptoms with their cardiac rhythms. This may include use of a Holter monitor or event recorder.

Imaging Studies

  • Transthoracic echocardiogram may reveal decreased cardiac output with ventricular pacing versus either conducted sinus activity or AV synchronous pacing. M-mode tissue Doppler imaging may reveal an altered ventricular activation pattern.
  • A study by Lee and associates demonstrated possible utility of transesophageal echocardiography in diagnosis of pacemaker syndrome. They noted higher atrial reverse flow velocities, increased frequency of spontaneous echo contrast in the descending aorta, and significant mitral regurgitation in ventricularly paced patients with pacemaker syndrome.

Other Tests

ECG may reveal a prolonged PR interval, VA conduction, or AV dissociation.

Procedures

Measure systolic blood pressure during ventricular pacing and compare to that during atrial or AV synchronous pacing. A drop of 20 mm Hg or more is suggestive of pacemaker syndrome.

More on Pacemaker Syndrome

Overview: Pacemaker Syndrome
Differential Diagnoses & Workup: Pacemaker Syndrome
Treatment & Medication: Pacemaker Syndrome
Follow-up: Pacemaker Syndrome
Multimedia: Pacemaker Syndrome
References
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References

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Further Reading

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Keywords

pacemaker syndrome, subclinical pacemaker syndrome, pseudopacemaker syndrome, atrioventricular dyssynchrony, AV dyssynchrony, arrhythmia, ventricular pacing

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Contributor Information and Disclosures

Author

Daniel M Beyerbach, MD, PhD,, Consulting Staff, Florida Electrophysiology Associates; Affiliate Clinical Assistant Professor of Biomedical Science, Florida Atlantic University, Regional Campus of University of Miami Miller School of Medicine
Daniel M Beyerbach, MD, PhD, is a member of the following medical societies: American College of Cardiology
Disclosure: Nothing to disclose.

Coauthor(s)

Christopher Cadman, MD, Director of Arrhythmia Service, Assistant Professor, Department of Internal Medicine, Division of Cardiology, University of New Mexico
Christopher Cadman, MD is a member of the following medical societies: American College of Cardiology and Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

Hanumant Deshmukh, MD †, Former Chief of Cardiology, Veterans Affairs Medical Center; Former Associate Professor, Department of Medicine, Rosalind Franklin University of Medicine and Science
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Brian Olshansky, MD, Professor of Medicine, Department of Internal Medicine, University of Iowa College of Medicine
Brian Olshansky, MD is a member of the following medical societies: American Autonomic Society, American College of Cardiology, American College of Chest Physicians, American College of Physicians, American College of Sports Medicine, American Federation for Clinical Research, American Heart Association, Cardiac Electrophysiology Society, Heart Rhythm Society, and New York Academy of Sciences
Disclosure: Guidant/Boston Scientific Honoraria Speaking and teaching; Medtronic Honoraria Speaking and teaching; Guidant/Boston Scientific Consulting fee Consulting; Reliant Grant/research funds Other; Novartis Honoraria Speaking and teaching; Novartis Consulting fee Consulting

CME Editor

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Chief Editor

Michael E Zevitz, MD, Assistant Professor of Medicine, Finch University of the Health Sciences, The Chicago Medical School; Consulting Staff, Private Practice
Michael E Zevitz, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Medical Association, and Michigan State Medical Society
Disclosure: Nothing to disclose.

 
 
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