Managing Pacemaker-Related Complications And Malfunctions In The Emergency Department (Cardiovascular CME)
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Managing Pacemaker-Related Complications And Malfunctions In The Emergency Department (Cardiovascular CME)

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Table of Contents
Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Epidemiology
  5. Critical Appraisal Of The Literature
  6. Review Of Normal Pacemaker Function
    1. Components And Lead Placement
    2. Pacemaker Modes
    3. Pacemaker Indications
      1. Sinus Node Dysfunction
      2. Acquired Atrioventricular Block
      3. Chronic Bifascicular Or Trifascicular Block
      4. After Acute Myocardial Infarction
      5. Cardiac Resynchronization Therapy
      6. Neurocardiogenic Syncope And Carotid Sinus Syndrome
  7. Emergency Department Evaluation
    1. History
    2. Physical Examination
  8. Diagnostic Studies
    1. Electrocardiogram
      1. Hyperkalemia
      2. Acute Myocardial Infarction
    2. Radiology
    3. Device Interrogation
  9. Implant-Related Complications
    1. Hematoma
    2. Infection
    3. Lead Dislodgement
    4. Twiddler Syndrome
    5. Venous Thrombosis
    6. Pneumothorax
    7. Tricuspid Regurgitation
    8. Pacemaker Syndrome
  10. Pacing System Malfunctions
    1. Failure To Capture
    2. Failure To Pace
    3. Failure To Sense
  11. Electromagnetic Interference
    1. Nonmedical Sources Of Interference
    2. Medical Sources Of Interference
  12. Management of Pacemaker-Related Complications and Malfunctions
    1. Approach To The Pacemaker Patient With Tachycardia
      1. The Magnet
    2. Advanced Cardiovascular Life Support In Patients With Pacemakers Or Implantable Cardioverter-Defibrillators
    3. Approach To The Pacemaker/Implantable Cardioverter-Defibrillator Patient Who Receives A Shock
  13. Disposition
  14. Controversies And Cutting Edge
    1. Remote Monitoring
    2. Leadless Pacing
    3. Device Deactivation
  15. Summary
  16. Risk Management Pitfalls For Implantable Devices
  17. Case Conclusions
  18. Clinical Pathway For Emergency Department Management Of Multiple
  19. Tables and Figures
    1. Table 1. American College of CardiologyAmerican Heart Association Classification Of Recommendations And Level Of Evidence
    2. Table 2. The North American Society For Pacing And ElectrophysiologyBritish Pacing And Electrophysiology Group Generic Pacemaker Code
    3. Table 3. Indications For Cardiac Resynchronization Therapy
    4. Table 4. Radiographic Assessment Of The Permanent Pacemaker/Implantable Cardioverter-Defibrillator
    5. Table 5. Methods To Identify Device Manufacturer
    6. Table 6. Implant-Related Complications
    7. Table 7. Causes Of Pacemaker Malfunction%2C By Category
    8. Table 8. Expected Response To Magnet Placement Over PacemakerImplantable Cardioverter-Defibrillator And Clinical Implications Of Different Magnet Responses
    9. Table 9. Clinical Applications Of Magnet On Implanted Cardiac Device
    10. Figure 1. Indications For Permanent Pacing
    11. Figure 2. Electrocardiogram Tracing Of Paced Rhythms In The Setting Of Severe Hyperkalemia
    12. Figure 3. Electrocardiogram Tracing Of Myocardial Infarction, Paced Rhythm
    13. Figure 4. Radiograph Of Dual-Chamber, Biventricular Pacemaker/Implantable Cardioverter-Defibrillator System
    14. Figure 5. Electrocardiogram Appearance of Pacemaker Failure
    15. Figure 6. Pacemaker-Mediated Tachycardia
  20. References


The use of implanted pacemaker devices is increasing worldwide, owing to technological advances, new indications, and an aging population. Despite greater experience in implantation and improved device sophistication, patients continue to face complications associated with hardware implantation and device malfunction. This review summarizes current indications for permanent pacing, reviews epidemiologic data relevant to implant complications, and describes a clinical approach to the patient with potential pacing malfunction. The electrocardiographic diagnosis of hyperkalemia and acute myocardial infarction in paced rhythms is also discussed. Potential sources of electromagnetic interference and special considerations pertaining to the cardiac resuscitation of patients with implanted cardiac devices are reviewed. Finally, a basic approach to implanted cardioverter-defibrillator devices (which often accompany pacemaker devices) is presented.

Case Presentations

An ill-appearing 74-year-old woman is brought in on a stretcher by EMS personnel who broke down her door to find her slumped on her couch. Her temperature is normal, her blood pressure is 86/40 mm Hg, and her heart rate is 42 beats/min. On the cardiac monitor, you see extremely wide QRS complexes following pacer artifacts and intermittent pauses where pacing artifacts appear alone. A prior ECG shows a paced rhythm and narrower QRS complexes. What are your critical actions?

A 38-year-old woman who fainted in the grocery store is wheeled into the last unoccupied room in your ED with a cardiac monitor. She has cardiac sarcoidosis and has a DDD pacemaker that was implanted 6 months ago. She tells you that this is the third time she has fainted in the past 24 hours. She is normotensive and her heart rate is 48 beats/min. The cardiac monitor shows pacing artifacts that are completely dissociated from QRS complexes. What steps will you take to diagnose the underlying cause of this patient’s recurrent syncopal episodes?


Cardiac pacemakers have evolved from singlechamber devices that deliver a fixed pacing rate to multichamber systems with programmable features that preserve and more closely mimic normal cardiac electrophysiology. Preservation of atrioventricular synchrony, physiologic heart rate, and interventricular synchrony are significant improvements that have been made possible with dual-chamber, rate-adaptive, and biventricular pacing systems. For patients, improved quality of life, increased exercise tolerance, and decreased disease progression are among the clinical outcomes driving new indications for pacemaker implantation and cardiac resynchronization therapy (CRT). At the same time, mortality benefits associated with implanted cardioverterdefibrillator devices (ICDs) in patients with heart failure have translated into an increasing number of biventricular pacing systems with integrated ICD technology. While pacemakers have become more complex and sophisticated, patients continue to present to the emergency department (ED) with symptoms related to device malfunctions. In addition, special considerations with regard to implanted pacemakers are relevant to the diagnostic workup of comorbid illnesses.


Implanted pacemakers are increasingly prevalent in the United States.1 Approximately 370,000 pacemakers are placed annually,2 the most common indication for which is sinus node disease.3 Regardless of the indication for pacing, dual-chamber pacemakers have been adopted as the technology of choice. However, since United States Food and Drug Administration (FDA) approval in 2001, CRT devices are being implanted more frequently.4 Most of these are combined with defibrillation technology, and CRT-defibrillator (CRT-D) devices have come to comprise approximately 40% of all pacemakers in the United States.5 Compared with the general population, patients receiving implanted devices are older (mean age of implantation of 75.6 years) and carry a higher burden of age-adjusted comorbid illness.1,6

Critical Appraisal Of The Literature

PubMed and the Cochrane Database of Systematic Reviews were searched for English-language articles pertaining to the management of patients with implanted pacemakers and cardiac devices published between January 1, 1990 and February 21, 2014. Search terms included permanent pacemakers and the thematic topics of pacemaker complications, cardiac resynchronization therapy, pacemaker malfunction, and electromagnetic pacemaker interfer ence. The bibliographies of review articles were hand-searched and the level of evidence graded according to the guidelines from the American Heart Association Task Force on Practice Guidelines. (See Table 1.) Guidelines published by the American College of Cardiology Foundation/ American Heart Association (ACCF/AHA), the Heart Rhythm Society (HRS), the European Heart Rhythm Association (EHRA), and the European Society of Cardiology (ESC) were also reviewed.7-11

Risk Management Pitfalls For Implantable Devices

  1. “The ventricular-paced rhythm makes the ECG uninterpretable for diagnosing MI. I’ll call cardiology if the troponin comes back positive.” While concordant ST-segment changes and exaggerated discordance are insensitive findings for diagnosing acute MI in paced rhythms, they are diagnostically useful, when present.
  2. “Pacing artifacts appear stranded among widened and regular QRS complexes at a ventricular rate of 42. There must be a problem with the pacemaker.” Hyperkalemia can cause QRS widening, bradycardia, and failure to capture. Obtain a serum potassium level quickly and consider immediate administration of calcium. Always consider hyperkalemia before attributing failure to capture to a hardware problem or programming error.
  3. “I thought electrical cardioversion was contraindicated in patients with permanent pacemakers.” Electric direct-current cardioversion is safe as long as the electrodes are placed in anterior-posterior orientation at least 8 cm away from the pacemaker device. Device interrogation for proper functioning should be performed after cardioversion.
  4. “Pacemaker-mediated tachycardia was on my differential, but I was afraid to place a magnet over the pacemaker.” A pacemaker magnet only disables the sensing function, not the pacing function, and it can be effective in terminating pacemaker-mediated tachycardia as well as for differentiating among various types of potential pacemaker malfunction.
  5. “I thought all newer pacemakers were MRI-compatible.” While advances in pacemaker design have led to the development of pacing leads and pulse generators that are safe for the magnetic environment, safe MRI requires careful screening, established protocols, and physician supervision.
  6. “I didn’t think to compare the chest x-ray with a previous one or consider lead dislodgement as a complication that could occur so far out from implantation.”Lead migration more commonly occurs shortly after implantation, but it can be a late complication. Comparison with previous x-rays is helpful in detecting macro lead dislodgements.
  7. “The 12-lead ECG appeared normal. I didn’t think the patient needed device interrogation.” Pacemaker interrogation is critical in evaluating the possibility of pacemaker dysfunction that might not be apparent on a 12-lead ECG.
  8. “The patient experienced syncope and has a pacemaker, so she is a high-risk cardiac patient and needs to be admitted to telemetry.” Pacemaker interrogation can be performed in the ED to rule out dysrhythmia and pacing malfunction as underlying causes of palpitations, syncope, and light-headedness. Device interrogation may help to avoid unnecessary hospital admission in some of these patients.
  9. “I didn’t think that hiccoughs could be related to the patient’s pacemaker.” Direct stimulation of the diaphragm or the phrenic nerve occurs with lead dislodgement or with high output from a left ventricular lead placed in the coronary sinus.
  10. “Ventricular tachycardia clearly wasn’t the cause of his symptoms. If he had ventricular tachycardia, his CRT-D device would have shocked him.”Ventricular tachycardia may occur at rates below the programmed tachycardia detection rate (TDR). Above the TDR, ICD therapy is administered. A low TDR can be programmed, with the risk of administering therapy inappropriately to supraventricular tachyarrhythmias. Antitachycardia pacing and algorithms to improve the specificity of VT detection have reduced the incidence of inappropriate ICD therapy for supraventricular arrhythmias.

Tables and Figures

Table 1. American College of CardiologyAmerican Heart Association Classification Of Recommendations And Level Of Evidence

Table 2. The North American Society For Pacing And ElectrophysiologyBritish Pacing And Electrophysiology Group Generic Pacemaker Code


Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference.

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  2. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics--2014 update: a report from the American Heart Association. Circulation. 2014;129(3):e28-e292. (Executive summary)
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Jennifer Martindale, MD; Ian S. deSouza, MD

Publication Date

September 2, 2014

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