Pacemaker therapy in the elderly patients

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					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
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