Indications and Recommendations for Pacemaker Therapy - American Family Physician

Volume 71, Number 8 www.aafp.org/afp American Family Physician 1563 S ince the first permanent pacemaker was implanted in 1958, device therapy has continued to grow. It is estimated that more than 300,000 patients in the United States receive a permanent pacemaker each year, and about 900,000 pacemakers are implanted worldwide. The indications for pacemaker therapy have expanded in the past 45 years and now include the treatment of bradyarrhythmias and the electrical therapy of tachyarrhythmias, certain types of syncope, and advanced heart failure. Device technology also has evolved from simple single-chamber, fixed-rate pacemakers to multichamber, rate-responsive (to meet physiologic needs) units capable of pacing, cardioversion, and defibrillation. In specific populations, clinical studies have demonstrated improvement of patient survival with the use of these implantable devices. The decision to implant a pacemaker usually is based on symptoms of a bradyarrhythmia or tachyarrhythmia in the setting of heart disease. Symptomatic bradycardia is the most common indication. It has been defined as a “documented bradyarrhythmia that is directly responsible for the development of the clinical manifestations of frank syncope or near syncope, transient dizziness or light-headedness, and confusional states resulting from cerebral hypoperfusion and attributable to low heart rates.”1 Other symptoms that may result from severe bradycardia include fatigue, reduced exercise capacity, and frank congestive heart failure. Physiologic sinus bradycardia, which can occur in highly trained athletes, must be excluded and should not be confused with pathologic bradyarrhythmias.