Patients with severe heart failure can get biventricular pacing for cardiac resynchronization. Commonly patients get both right atrium and right ventricle paced and sensed, with the option of triggered activity (eg atrial activity triggers ventricular pacing) or inhibited activity (atrial activity inhibits atrial pacing, and ventricular pacing inhibits ventricular pacing) – in other words DDD. In patients with AF and slow ventricular response, only the ventricle needs to be paced, and if ventricular activity is sensed the pacing is inhibited (VVI). For example, patients with sinus node dysfunction but normal conduction might only need their atria paced, and if intrinsic atrial activity is sensed the pacing is inhibited (AAI). Pacemakers are classified by a sequence of 3 letters specifying 1) the chamber(s) being paced (Atrial, Ventricular, or Dual), 2) the chamber(s) being sensed (Atria, Ventricular, Dual, or none), and 3) the response to sensing (Triggered, Inhibited, Dual, or none). Atrial pacing in the right atrium produces a P wave similar to normal sinus rhythm, while right ventricular pacing mimics bundle branch block (usually LBBB, with a left axis and no R wave progression, from a pacemaker in the apex of the right ventricle). PACER mnemonic: ECG Approach to pacemaker patientsĬommon indications for permanent pacing include sinus node dysfunction causing symptomatic bradydysrhythmias, AV block, cardiac resynchronization for severe heart failure, or for termination of tachydysrhythmias. Old then new:Ĭase 9: 75 year old, history CAD, VVI pacemaker for AF, with few days weakness and presyncope. Old then new:Ĭase 3: 85 year old, DDD pacemaker for sinus pauses, with pleuritic chest pain 5 days after pacemaker insertionĬase 4: 90 year old, history CAD and CHF with biventricular pacemaker, on spironolactone, with few days of weaknessĬase 5: 75 year old, DDD pacemaker for hypertrophic cardiomyopathy, with an hour of chest pain and nauseaĬase 6: 85 year old, history inferior MI, VVI pacemaker for AF with slow ventricular response, with acute chest painĬase 7: 100 year old, history aortic stenosis and AF, VVI pacemaker for AV block, with generalized weakness, trop 300 ng/LĬase 8: 75 year old, DDD pacemaker for AV block, with weakness and confusion, HR 110 and BP 90. What’s the diagnosis, and is it related to the pacemaker or the patient?Ĭase 1: 85 year old, history of MI, DDD pacemaker for AV block, with palpitationsĬase 2: 80 year old, VVI pacer for AF with slow ventricular response, with shortness of breath, weakness and dizzy. 9 pacemaker patients presented to the ED.
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