Pacemaker Syndrome Treatment & Management

  • Author: Daniel M Beyerbach, MD, PhD; Chief Editor: Jeffrey N Rottman, MD   more...
 
Updated: Jan 4, 2012
 

Medical Care

  • For ventricularly paced patients, addition of an atrial lead and institution of AV synchronous pacing usually resolves symptoms.
  • In patients with other pacing modes, symptoms usually resolve after interrogation and reprogramming of pacemaker parameters, such as AV delay, postventricular atrial refractory period, sensing level, and pacing threshold voltage. In many cases, optimal parameter values may be obtained experimentally with successive reprogramming and measurement of pertinent parameters, such as blood pressure, cardiac output, and total peripheral resistance, as well as observations of symptomatology.
  • In rare instances, using hysteresis to help maintain AV synchrony can help alleviate symptoms in patients with VVI pacemakers and intact sinus node function. For example, if pacing rate is 60 beats per minute (bpm), the hysteresis rate can be programmed to be 50 bpm; in this way, pacing is not instituted until the native ventricular rate falls below 50 bpm, but when pacing is instituted, the pacemaker rate is 60 bpm. Hysteresis effects a reduction in the amount of time spent in pacing mode, which can alleviate symptoms, particularly when the pacing mode, such as VVI, is generating AV dyssynchrony.
  • Additional treatment modalities include replacing the pacemaker pulse generator and revision of medication regimen.
  • Medical care includes supportive care in relation to possible heart failure, hypotension, tachycardia, tachypnea, and oxygenation deficit.
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Surgical Care

Consultation with an electrophysiologist determines the possible need for additional pacemaker lead placement.

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Consultations

Electrophysiology should be consulted for specialized care related to the pacemaker and for procedures to aid in diagnosis and treatment of pacemaker syndrome.

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Diet

  • Low-salt diet is indicated for patients with heart failure.
  • For patients with autonomic insufficiency, a high-salt diet may be appropriate.
  • For patients with dehydration, oral fluid rehydration is needed.
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Activity

Patients may engage in activities as tolerated.

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Proceed to Medication
 
 
Contributor Information and Disclosures
Author

Daniel M Beyerbach, MD, PhD  Medical Director, Cardiac Rhythm Program, The Christ Hospital; Affiliate Clinical Assistant Professor of Biomedical Science, Florida Atlantic University

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.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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; Novartis Honoraria Speaking and teaching; Novartis Consulting fee Consulting

Amer Suleman, MD  Private Practice

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

Jeffrey N Rottman, MD  Professor of Medicine and Pharmacology, Vanderbilt University School of Medicine; Chief, Department of Cardiology, Nashville Veterans Affairs Medical Center

Jeffrey N Rottman, MD is a member of the following medical societies: American Heart Association and North American Society of Pacing and Electrophysiology (NASPE)

Disclosure: Nothing to disclose.

References

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Pronounced PR interval prolongation. The effect of this PR interval prolongation on AV dyssynchrony is demonstrated in this ECG image.
AV dyssynchrony resulting from severe PR interval prolongation in the setting of sinus rhythm. In this ECG, the PR interval is prolonged to the point that the P wave occurs coincident with the peak of the T wave. Compare to the prior image of the same patient with a slower sinus rate.
Accelerated idioventricular rhythm with retrogradely conducted P waves. This ECG demonstrates a mechanism of AV dyssynchrony that might lead to pseudopacemaker syndrome.
Junctional rhythm with retrogradely conducted P waves. If symptoms of pacemaker syndrome develop, increasing the lower rate limit for pacing may help to restore AV synchrony.
Retrogradely conducted P waves are visible directly following each ventricular-paced complex.
This is an ECG tracing of a patient with continuous atrioventricular synchronous (DDD) pacing prior to development of symptoms. Atrial stimulation (open arrows) is followed by visible P waves. Wide QRS complexes follow ventricular stimulation (solid arrows).
This is an ECG tracing of a patient with atrioventricular (AV) dissociation and resultant pacemaker syndrome. Native atrial depolarizations (arrows) move progressively closer to pacemaker-stimulated ventricular depolarizations. Ventricular pacemaker stimuli (arrowheads) are greater in amplitude than those visible in the previous image, consistent with mode reversion from AV synchronous (DDD) to ventricular inhibited (VVI), which includes a switch from bipolar pacing (low amplitude) to unipolar pacing (higher amplitude).
Table. Incidence of Atrial Fibrillation in Patients with Pacemakers
Study Patients



(number)



Total Incidence



(%)



Follow-up



(years)



Annual Incidence



(%)



VVI AAI DDD VVI AAI DDD
Frielingsdorf[25] 1838 18-47 0-17* 3.75 4.8-12.5 0-4.5*
Sutton and Kenny[26] 1061 22 3.9 AAI: 2.75



VVI: 3.25



6.77 1.42
Hesselson[27] 8827 14-57 0-23 AAI: 1-8



VVI: 3-8



Cannot be determined
Hesselson[27] 950 38 7 7 5.43 1.00
Santini[28] 339 48 3.7 13 5 9.6 0.74 2.6
Sasaki[29] 75 41 2* AAI: 3.25



VVI: 5.17



7.9 0.62*
Rosenqvist[30] 168 47 6.7 4 11.8 1.68
*Combined AAI and DDD
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