History
No specific set of criteria has been developed for diagnosis of pacemaker syndrome. Most of the signs and symptoms of pacemaker syndrome are nonspecific, and many are prevalent in the elderly population at baseline. [43] Diagnosis from history depends heavily on correlation between onset of symptoms and onset of pacing or change in pacing mode, with attention to type and severity of symptoms. In the clinical setting, pacemaker interrogation and programming plays a crucial role in determining pacemaker mode contribution to symptoms.
Symptoms
In their detailed review of pacemaker syndrome, Ausubel and Furman [31] categorized symptoms on the basis of presumed etiology. Augmenting their list with that of Ellenbogen and colleagues [8] provides the following:
-
Neurologic: Dizziness, near syncope, and confusion
-
Heart failure: Dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and edema
-
Hypotension: Apprehension, mental status change, diaphoresis, and signs of orthostasis and shock
-
Low cardiac output: Fatigue, weakness, dyspnea on exertion, lethargy, and lightheadedness
-
Hemodynamic: Pulsation in the neck and abdomen, choking sensation, jaw pain, right upper quadrant (RUQ) pain, chest colds, headache
-
Arrhythmias: Palpitations
-
Rate related: Chest fullness or pain
Physical Examination
The focus of physical examination is on findings related to etiologies of symptoms mentioned in History. In particular, the examiner should look for the following [44] :
-
Vital signs may reveal hypotension, tachycardia, tachypnea, or low oxygen saturation.
-
Pulse amplitude may vary, and blood pressure may fluctuate.
-
Look for neck vein distension and cannon waves in the neck veins.
-
Lungs may exhibit crackles.
-
Cardiac examination may reveal regurgitant murmurs and variability of heart sounds.
-
Liver may be pulsatile, and the RUQ may be tender to palpation. Ascites may be present in severe cases.
-
The lower extremities may be edematous.
-
Neurologic examination may reveal confusion, dizziness, or altered mental status.
-
Pacemaker Syndrome. Pacemaker syndrome without pacemaker participation. Displayed are stored data from a dual-chamber pacemaker. The intracardiac tracings reveal atrial tachycardia with second-degree AV block that together created continuous atrioventricular (AV) dyssynchrony, leading to symptoms of pacemaker syndrome, including fatigue, lightheadedness, and exertional dyspnea. Notice that the pacemaker does not participate in creation of AV dyssynchrony. There are no paced events. Top tracing: atrial electrogram. Middle tracing: ventricular electrogram. Bottom tracing: channel markers. Ab = atrial sensed event in postventricular blanking period, AR = atrial sensed event in postventricular refractory period; VS – Ventricular sensed event.
-
Pacemaker Syndrome. Pronounced PR interval prolongation. The effect of this PR interval prolongation on AV dyssynchrony is demonstrated in this ECG image.
-
Pacemaker Syndrome. 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.
-
Pacemaker Syndrome. Accelerated idioventricular rhythm with retrogradely conducted P waves. This ECG demonstrates a mechanism of AV dyssynchrony that might lead to pseudopacemaker syndrome.
-
Pacemaker 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.
-
Pacemaker Syndrome. Retrogradely conducted P waves are visible directly following each ventricular-paced complex.
-
Pacemaker Syndrome. 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).
-
Pacemaker Syndrome. 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).
Tables
Study |
Patients (number) |
Total Incidence (%) |
Follow-up (years) |
Annual Incidence (%) |
||||
|
|
VVI |
AAI |
DDD |
|
VVI |
AAI |
DDD |
Frielingsdorf [34] |
1838 |
18-47 |
0-17* |
3.75 |
4.8-12.5 |
0-4.5* |
||
Sutton and Kenny [35] |
1061 |
22 |
3.9 |
|
AAI: 2.75 VVI: 3.25 |
6.77 |
1.42 |
|
Hesselson [36] |
8827 |
14-57 |
0-23 |
|
AAI: 1-8 VVI: 3-8 |
Cannot be determined |
||
Hesselson [36] |
950 |
38 |
7 |
|
7 |
5.43 |
1.00 |
|
Santini [37] |
339 |
48 |
3.7 |
13 |
5 |
9.6 |
0.74 |
2.6 |
Sasaki [38] |
75 |
41 |
2* |
AAI: 3.25 VVI: 5.17 |
7.9 |
0.62* |
||
Rosenqvist [39] |
168 |
47 |
6.7 |
|
4 |
11.8 |
1.68 |
|
*Combined AAI and DDD |
||||||||
