Journal of Geriatric Cardiology June 2007 Vol 4 No 2 127 Editorial Pacemaker therapy in the elderly patients Jose Antonio Lapuerta-Irigoyen, Santiago Herrero Pacemaker and Coronary Unit, Intensive Care Service, Cabueñes Hospital, Gijon, Spain The treatment of choice in symptomatic cases of implantation (observational data, non published). Specific patients with severe bradycardia remains the implantation studies are not known, that analyze factors of mortal risk in of a pacemaker. 1, 2 In the Western countries, the increase in this population. A previous history of equivalent syncope life expectancy, along with programs of universal medical and masculine gender could affect their survival. 3 assistance in the elderly has shown that implants of pacemakers are on the rise (32% implants in patients >80 Stimuli modalities year). 3 Also, the high economic cost, associated to the Present technology allows the electric stimulation in electrotherapy has given rise to a great controversy, either a single (ventricle or atrium) or dual chamber fashion. including the optimal selection of the way of stimulation, Single lead pacemakers are less expensive, easy to implant strategy of implantation and clinical benefit of pacemakers and monitoring. In addition, the battery is superior in length usage in patients of >80 years. of life when compared with the dual chamber systems. Dual The high prevalence of cardiovascular disease in the lead pacemakers preserve the atrial and ventricular stimuli elderly, entails that the rhythm disorders are very frequent as well as chronotropic response, thus presenting a more in this age group. The clinical presentation can be various physiologic situation. 8 However in the daily practice, the in many situations. Some cases of bradycardia may present elderly patient is rarely benefits from the use of two-lead without symptoms while others show a neurological pacemaker technology. 9 We have some information, with predominance (light-headedness or syncope equivalent, respect to survival according to the mode of stimulation. confusion, awkwardness). Perhaps this must be accounted Although some retrospective studies suggest a greater for by the existence of vascular disease and the greater survival with the dual chamber stimulation after 2 years, 7 vascular rigidity in the cerebral vessels of the elderly. later retrospective studies like the CTOPP-trial, 10, 11 the The co-existence of structural cardiomyopathy can be MOST-trial, 12 and recently trial UK-PACE, 13 show that the a ccomp a nied by grea ter or s ma ller hemodyna mic selection of the mode of stimulation, single or dual chamber repercussion. Frequently they are also using medication does not affect survival differences in elderly patients with (aspirin, angiotensin-converting enzyme inhibitor, warfarin, atrioventricular block after 4 years of follow-up. 14 etc.) 4 which may alter the physiology of the situation. It is The frequency of atrial fibrillation appears greater in essential then to make a complete evaluation of the patient this population as well, particularly in those with disease of towards to diagnose of a possible structural cardiomyopathy the sinus node during a relatively short period of observa- which may ultimately affect the prognosis of these patients tion (average 18 months). 15 The appearance of atrial thus altering the decision for pacemaker implantation. fibrillation, does not demonstrate an increase in mortality, functional impairment, stroke or hospital admissions. Survival Another aspect in these patients is the possibility of The long term survival of the patients with pacemakers appearance of pacemaker syndrome that is lowered cardiac has been poorly studied to date. 5-7 After the implant of output related to the retrograde conduction (ventricle-atrial) pacemakers in patients of >80 years, survival approximates during the ventricular stimulation. This has been described 66% at 5 years compared with 37% and 47% of previous in as high as 26% of implants which may force the implant- decades. In nonagenarians (90 years or older), the mean ers to choose a dual chamber system over the single ven- survival of patients after pacemaker implantation was 37.4 tricular chamber mode. 12 It seems that the dual chamber months (nearly 3.1 years). It appears that 76.4%, 51.8%, and pacing stimulation in the sub-group of sick sinus syndrome, 34.2%, respectively, were still alive at 1, 3, and 5 years after improves the quality of life when compared in the sub-group with atrioventricular block. C o r r esp o n d i n g a u t h o r : S a n t i a g o H e r r e r o , M D , Un i da d d e Cu ida dos Intensivos, Hospital de Ca bu eñes, Gijón, Spain. Ethical considerations E-ma i l: she rrer o@g ma i l.c om When symptomatic elderly patients are near the end 128 Journal of Geriatric Cardiology June 2007 Vol 4 No 2 of their life, medical interventions become more complicated, in very elderly patients: long-term survival and prognostic expensive and probably less effective. Frequently clinicians parameters. Am Heart J 2003;146:908-13. may cast some doubts, on the mental capacity of the elderly, 4. Ganz DA, Lamas GA, Orav EJ, et al. Age-related differences in management of heart disease: a study of cardiac medication use thus affecting clinical decision making. In this context, ob- in an older cohort. Pacemaker Selection in the Elderly (PASE) taining “informed consent” previous to any surgical inter- Investigators. J Am Geriatr Soc 1999;47:145-50. vention requires special considerations, different from that 5. Shen WK, Hammill SC, Hayes DL, et al. Long-term survival which is taken in the daily practice. Frequently the relatives after pacemaker implantation for heart block in patients > or of these patients must explain to the patient the ultimate =65 years. Am J Cardiol 1994;74:560-4. prognosis and help them in their decision making. 16 6. Shen WK, Hayes DL, Hammill SC, et al. Survival and functional independence after implantation of a permanent pacemaker in Economic costs octogenarians and nonagenarians. A population-based study. Given the limited life expectancy that is displayed in Ann Intern Med 1996;125:476-80. 7. Lamas GA, Pashos CL, Normand SL, McNeil B. Permanent these patients, the cost/benefit ratio for pacing has given pacemaker selection and subsequent survival in elderly Medicare rise to serious controversies as far as its “economic yield”. pacemaker recipients. Circulation 1995; 91:1063-9. Schmidt, et al.17 reviewed a series of 1,588 patients of age > 8. Samet P, Castillo C, Bernstein WH. Hemodynamic consequences 80, which revealed a cost by patient/year of = $500.00 US of atrial and ventricular pacing in subjects with normal hearts. Dollars on the basis of 8 years average survival. This would Am J Cardiol 1966;18:522-5. then favor the aggressive usage of pacemakers in these 9. Jahangir A, Shen WK, Neubauer SA, et al. Relation between mode octogenarians despite limited life expectancies. of pacing and long-term survival in the very elderly. J Am Coll Cardiol 1999;33:1208-16. Conclusion 10. Connolly SJ, Kerr CR, Gent M, et al. Effects of physiologic pacing versus ventricular pacing on the risk of stroke and death We are observing a progressive increase in the num- due to cardiovascular causes. Canadian Trial of Physiologic ber of elderly patients in whom pacemakers appear Pacing Investigators. N Engl J Med 2000;342:1385-91. indicated. The life expectancy in these patients and the low 11. Tang AS, Roberts RS, Kerr C, et al. Relationship between cost of follow-up suggest that pacing therapy in elderly pa cema ker dependency a nd the effect of pa cing mode on with symptomatic bradycardia be an effective and viable cardiovascular outcomes. Circulation 2001; 103:3081-5. option. From a clinical point of view, the low complication 12. Lamas GA, Orav EJ, Stambler BS, et al. Quality of life and numbers and reasonable costs make it prudent to treat these clinical outcomes in elderly patients treated with ventricular individuals just as we would if they were younger. The dual pacing as compared with dual-chamber pacing. Pacemaker chamber stimulation would have to be considered in pa- Selection in the Elderly Investigators. N Engl J Med 1998; 338: 1097-104. tients with sick sinus disease in the absence of atrial fibril- 13. Toff WD, Skene AM, Camm AJ, et al. A prospective comparison lation which will result in the subjective improvement and of the clinical benefits of dual chamber versus single chamber quality of life. ventr icu la r pa cing in e lderly p a tients with high gra de a trioventricula r block : The United Kingdom Pa cing and References Cardiovascular Events (UKPACE) Trial. J Am Coll Cardiol 2003;41(6 Suppl A):10. 1. Gregoratos G, Abrams J, Epstein AE, et al.; American College of 14. Toff WD, Camm AJ, Skehan JD; United Kingdom Pacing and Cardiology/American Heart Association Task Force on Practice Cardiovascular Events Trial Investigators. Single-chamber versus Guidelines American College of Cardiology/American Heart As- dual-chamber pacing for high-grade atrioventricular block. N sociation/North American Society for Pacing and Electrophysi- Engl J Med 2005;353:145-55. ology Committee. ACC/AHA/NASPE 2002 guideline update for 15. Stambler BS, Ellenbogen KA, Orav EJ, et al.; Pacemaker Selection implantation of cardiac pacemakers and antiarrhythmia devices: in the Elderly Trial Investigators. Predictors and clinical impact summary article. A report of the American College of Cardiol- of atrial fibrillation after pacemaker implantation in elderly ogy/American Heart Association Task Force on Practice Guide- patients treated with dual chamber versus ventricular pacing. lines (ACC/AHA/NASPE Committee to Update the 1998 Pace- Pacing Clin Electrophysiol 2003;26:2000-7. maker Guidelines). J Cardiovasc Electrophysiol 2002;13:1183- 16. Basta LL. End-of-life and other ethical issues related to pacemaker 99 . and defibrillator use in the elderly. Am J Geriatr Cardiol 2006;15: 2. Oter Rodriguez R, Montiel JJ, Roldan Pascual T, et al. Clinical 114-7. practice guidelines of the Spanish Society of Cardiology on 17. Schmidt B, Brunner M, Olschewsky M, et al. Pacemaker therapy pacemakers. Rev Esp Cardiol 2000;53:947-66. (in Spanish) in very elderly patients: long-term survival and prognostic 3. Schmidt B, Brunner M, Olschewsky M, et al. Pacemaker therapy parameters. Am Heart J 2003;146:908-13.
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