Diagnostic Considerations

In the setting of asymptomatic sinus bradycardia, implantation of a VVI pacemaker may induce symptoms of pacemaker syndrome. Even though this may be a class 2a indication for pacemaker implantation, the potential exists for worsening of quality of life. Thus, individuals may develop a subjectively worse quality of life with ventricular pacing than they had prior to pacemaker implantation, or they may endure a persistently degraded quality of life, as suggested by Sulke's study of subclinical pacemaker syndrome.

Other conditions to be considered in patients with suspected pacemaker syndrome include the following:

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

Differential Diagnoses

Workup

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Media Gallery

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).

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Table. Incidence of Atrial Fibrillation in Patients with Pacemakers

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^[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

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Pacemaker Syndrome Differential Diagnoses

Diagnostic Considerations

Differential Diagnoses

References

Tables

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