American Heart Journal
Volume 146, Issue 5 , Pages 750-753, November 2003

Pacing in elderly patients☆

  • Arshad Jahangir, MD

      Affiliations

    • Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn, USA
    • ,
  • Win K Shen, MD

      Affiliations

    • Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn, USA
    • Corresponding Author InformationReprints requests: Win-Kuang Shen, MD, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905-0001, USA.

Article Outline

 

See related article on page 908.

Aging is associated with progressive fibrosis of the sinoatrial node1 and the atrioventricular (AV) conduction system,2 resulting in bradycardia, which is further exaggerated by disease and medications and causes symptoms requiring permanent pacemaker implantation. More than 80% of pacemaker recipients in the United States are aged >65 years.3, 4 An estimated 35 million people (about 12.6% of the population) in the United States are currently 65 years and older,5 and it is projected that the elderly population will double, to >65 million (about 20% of the population), by the year 2030.5 Within the elderly group, the fastest growing age segment is that of the “older-elderly,” defined as those ≥80 years of age.5 The distribution and allocation of health resources, including cardiac devices, will be greatly affected by this rapidly growing segment of the population. Increasing demand on the health care system and higher infrastructural costs are already evident.6 A heightened need, therefore, exists to understand the characteristics of elderly patients who can benefit from the use of sophisticated technology, so that evidence-based strategies can be applied in a cost-effective manner, to achieve a longer active life free of disability.

In this issue of the Journal, Schmidt et al7 report secular trends in the demographic characteristics of older-elderly (>80 years) patients receiving permanent pacemakers and outcome on long-term survival after pacemaker implantation in the last 3 decades (1971–80, 1981–90, 1991–2000). The study involves a large cohort (1588) of older-elderly patients who received a permanent pacemaker between 1971 and 2000 and were followed-up for >5200 patient-years at their institution in Freiburg, Germany. The number of older-elderly patients who received a pacemaker increased significantly over the last 2 decades of the study period, with an almost doubling of the number of patients with pacemakers between 1971 to 1980 and 1980 to 1990, but then plateaued with no further increase in the 1990s. Older-elderly patients accounted for almost one third of all patients undergoing pacemaker implantation between 1991 to 2000. The number of women requiring pacemaker therapy increased by about 16% over the 3 decades, accounting for 57% of all pacemaker implants in older-elderly patients in the last decade. The proportion of pacemakers implanted for severe sinus bradycardia almost doubled from 18% in 1971 to 1980 to 34% in 1991 to 2000 and those with presyncope almost tripled, from 6% in 1971 to 1980 to 18% in 1991 to 2000, with no statistically significant change in the proportion paced for syncope or nonsyncopal bradycardia. The overall survival of this older-elderly group with pacemakers also appeared to improve over the last 30 years, with 5-year survival increasing from 37% in the 1970s, to 47% in the 1980s, and 66% in the 1990s. The pacemaker selection in this study was not randomized and was based on physician's discretion, with preference for physiologic AV-sequential pacing once the dual-chamber devices became available in 1986. The number of patients receiving DDD pacing increased from 0% in 1971 to 1980 to 15% and 61% in the last 2 decades. The difference in overall 3-year survival in the 1990s between those receiving DDD pacing and VVI pacing (78.7% vs 72.6%) was not significantly different. On multivariate analysis, the relative risk of death was lower in those who had pacemaker implantation in the last decade and those who had a history of presyncope, whereas, age >85 years at implant, male sex, and VVI pacing were associated with poor long-term survival.

This interesting study7 provides a unique historical perspective on pacing in older-elderly patients. The overall increase in the number of pacemaker implants in very elderly patients is consistent with those reported in other communities8, 9, 10 and may reflect the improvement in overall life expectancy, with a greater number of patients surviving beyond 80 years of age over the last 3 decades.5 It is not clear whether this increase simply represents changes in the regional population demographics, clinical practice (hospital or medical staff capacity), or actually represents an increase in the incidence of symptomatic bradycardia associated with a reduction in overall cardiovascular mortality and an increase in survival. The increase in the number of women receiving pacemaker therapy is an interesting statistic, but again it is not clear whether this reflects changes in the population demographic, an increase in the incidence of symptomatic bradycardia, or a decrease in the sex bias that may have influenced resource utilization in the earlier decades of the study.11, 12, 13

The beneficial impact of pacing in reducing morbidity and improving quality of life in symptomatic conduction system disease has been well documented.14, 15, 16, 17, 18, 19, 20, 21, 22, 23 By maintaining AV synchrony, atrial- or dual-chamber pacing may confer a “physiologic” advantage over ventricular pacing and improve effort tolerance and general well-being,16, 17, 18 along with reducing morbidity due to decreased incidence of atrial fibrillation,18, 19, 22, 23 thromboembolism,19, 20, 21 “pacemaker syndrome,”16 and congestive heart failure.18, 19, 20 However, the existence of a differential impact on survival of synchronous versus asynchronous atrioventricular pacing has not been demonstrated in randomized, prospective clinical trials.16, 18, 23 The conclusion of most of the earlier studies, which were nonrandomized and retrospective and suggested a deleterious effect on survival with ventricular pacing, should be interpreted in light of their limitations, including the inability to control for important baseline clinical differences and comorbidities between patients with different pacing modes.23, 24, 25, 26 When the baseline differences between those paced with ventricular versus a dual-chamber system were accounted for, the apparent survival benefit seen with dual-chamber pacing disappeared,26 indicating selection bias in choosing the ventricular pacing for older and sicker patients.22, 26

In the current study,7 the authors do not provide any information on improvement in symptoms or reduction in morbidity but indicate that the overall survival improved over the last 3 decades. The study does not provide any data to show whether this was directly related to the use of the more sophisticated pacing modes in the 1980s and 1990s or simply signifies the overall improvement in medical care achieved over this period of time.27, 28 A major weakness of this study is that the baseline characteristics, such as the underlying comorbid illnesses, cardiac dysfunction, and heart failure status, are not provided. The increased morbidity and mortality in patients with ventricular pacing in 1971 to 1980 compared to the later decades may well be related to differences in underlying cardiovascular disease and coexisting noncardiac conditions rather than the pacing system selected. The increase in the number of pacemaker implantations in low-risk patients (women, those with sinus node dysfunction as opposed to AV block, and those with milder symptoms) in the later decades could also underlie the “improvement” in observed survival. Results from recent prospective studies,16, 18, 23, 29, 30 although not limited solely to the older-elderly segment of the population, suggest the time-dependent survival benefit observed in the current study is not likely to be related to the changes in the pacing mode. Although the cost-effectiveness of pacing in elderly patients suggested by the authors is intriguing, complexity in medical economics analysis is well recognized.31, 32, 33 In the absence of controls and data on quality of life, symptoms, reduction in morbidity, hospitalization, and other related health care utilization and mortality, cost-effectiveness cannot be adequately assessed.

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Unanswered questions and future research in the older-elderly patients requiring pacemakers 

The effect on cardiac hemodynamics of pacing with the traditional right ventricular (RV) apical lead placement in elderly patients has not been explored. The abnormal ventricular activation sequence (from the apex to base and the right to left ventricle) with RV apical pacing, compared to the normal ventricular activation by the His-Purkinje system, appears to adversely affect hemodynamics, with reduction in cardiac output and an increase in pulmonary capillary wedge pressure.34 The hemodynamic deleterious effect via RVA pacing could be exaggerated in older-elderly patients, in whom reduced ventricular compliance is frequently present.4, 35 Further studies to assess the optimal pacing site and the differences between dyssynchronous and synchronous ventricular pacing36 in elderly patients with and without ventricular dysfunction will be needed.36a Moreover, in elderly patients with atrial fibrillation, the role of ventricular pacing (asynchronous vs synchronous) with AV conduction system ablation37 versus medical therapy for ventricular rate control or control of paroxysmal atrial fibrillation with new pacing algorithms on morbidity, quality of life, hospitalization, and health care utilization need to be further defined.

The selection of the pacing system has important clinical and economic implications.38 With advances in technology, sophisticated pacemaker systems are available to help ameliorate symptoms related to bradycardia and cardiac dysfunction. However, these devices are expensive and more complex when compared with single-chamber pacemakers. In the current cost-containment environment with ever-shrinking resources, the continuous increase in the aging population requiring pacemaker therapy poses a special challenge.39 Whether the increased cost and complexity as well as the frequent follow-up required by these pacing systems offset the clinical benefits in older-elderly patients is not clear. This is mainly because the impact of pacing mode is more difficult to establish in very elderly patients with nonspecific vague symptoms, high prevalence of coexisting illnesses, and shorter life expectancy. Elderly patients with pacemakers comprise a highly heterogeneous group, with variable functional capabilities, severity of cardiac diseases, coexisting medical illnesses, and life expectancy.40 Pacing mode selection in elderly patients, therefore, must be individualized according to the underlying rhythm disorders, activity level, and cardiovascular and noncardiac comorbidities so as to provide optimal functional benefit with minimal complications related to inappropriate pacing and cost. Atrial-based pacing compared to ventricular pacing may improve quality of life and decrease risk of atrial fibrillation and thromboembolic events; however, no clear benefit with regard to longevity may be obtained. The results of recent prospective randomized trials16, 18, 23 comparing various pacing modes in patients with sinus node dysfunction and conduction disease have helped to clarify many uncertainties with regard to mortality benefit and effect on quality of life and morbidity. It is expected that further issues related to pacing in elderly patients may be resolved as results from extended follow-up of patients from these16, 18, 23 and other ongoing30 and planned clinical trials become available.

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☆ AJ is supported by the grants from the National Institute on Aging (AG21201-01), the American Heart Association (02-30133N) and the Mayo Foundation for Research and Education (CR75 Research Award). WKS is supported by two grants from the National Institutes of Health (P50NS 32352-7 and R01HL 70302-1).

PII: S0002-8703(03)00454-X

doi:10.1016/S0002-8703(03)00454-X

American Heart Journal
Volume 146, Issue 5 , Pages 750-753, November 2003

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