Cardiac Pacing in elderly has its unique challenges. Although pacing is now a straightforward procedure with minimal complications, certain aspects of pacing need to be given unique consideration when faced with elderly patients.
Cardiac Pacing In Elderly
Most of cardiac pacing is done in mid to late adulthood. Degenerative disease & ischemia are the predominant conditions which lead to indications for pacing in adults. Since general medical care has improved, many patients with other cardiac conditions (e.g. Coronary artery disease) and non cardiac disease (e.g Diabetes, renal disease) survive to late adulthood allowing time for manifestation of conduction defects necessitating pacing. Some adults by virtue of good lifestyle live very well up to their 80s and 90s but develop conduction defects due to ageing and degeneration. Fall prevention is a major goal of cardiac pacing in elderly and even a mild sick sinus or a very rare intermittent AV block might need pacing solely to prevent a fall.
Elderly patients (>8O years) have poor cardiovascular reserve i.e. – they do well in usual day to day activities but when stressed their cardiovascular reserve is inadequate and complications develop rapidly. Certain aspects need to be considered when pacing an elderly patient to minimizing stressing his or her reserve.
Before Permanent Cardiac Pacing
This is the most neglected aspect of pacing in elderly. A proper pre-pacing plan is essential to prevent complications.
Need for Temporary Pacing
If there is symptomatic acute, ongoing rhythm disturbance (e.g. active complete heart block) – A temporary wire has to be placed to stabilize the patient. Although its not appreciated, acute rhythm disturbances lead to widespread non cardiac effects (renal , liver & cognitive impairment) – and permanent pacing in a deranged environment can lead to problems. Its best to give a period of stabilization with temporary pacing and proceed to permanent pacing.
Need for Permanent Pacing
Assessment of Co-morbidities
What co-morbidity is present that will interfere with the implantation ? E.g. de-compensated heart failure, de-compensated renal failure, decompensated liver disease etc. will lead to difficulties during permanent pacing and is best to get them under control with the support of temporary pacing beforehand
Assessment of Chronic Issues
Strokes, long-term hemodyliasis, cognitive impairment, anti-coagulation issues etc. can impact pacing procedure and needs pre-planning – See here for discussion on pre-procedure optimization and planning