What is the management of a patient in the inpatient setting after pacemaker (permanent artificial cardiac pacemaker) placement?

From the Guidelines

Patients who are not pacemaker-dependent and are free of complications should be monitored in the hospital for 24 hours after the implantation procedure, with a careful examination protocol followed before discharge, including evaluation of the wound and generator pocket, 12-lead ECGs, upright postero-anterior and lateral chest radiograph, and appropriate programming of primary pacing and sensing parameters 1.

Post-Implantation Monitoring and Care

In the inpatient setting, after pacemaker placement, the focus should be on monitoring for any immediate complications and ensuring the proper functioning of the pacemaker. This includes:

• Continuous monitoring of the patient's cardiac rhythm for at least 24 hours to quickly identify any pacemaker malfunctions or arrhythmias.
• Regular inspection of the incision site for signs of infection or hematoma formation.
• Administration of prophylactic antibiotics, such as cefazolin, for 24 hours post-procedure to prevent infection 1.
• Management of pain with medications like acetaminophen and, if necessary, oxycodone.
• Restricting arm movement on the side of the implant to prevent lead dislodgement, advising against raising the arm above shoulder level, lifting more than 5 pounds, or performing vigorous activities for 4-6 weeks.

Pre-Discharge Assessment

Before the patient is discharged, several key assessments must be made, including:

• A 12-lead ECG to evaluate the pacemaker's electrical function and ensure proper pacing and sensing parameters are set 1.
• An upright postero-anterior and lateral chest radiograph to confirm the correct placement of the leads and rule out complications like pneumothorax.
• Pacemaker interrogation to verify the device is functioning correctly, including checking threshold testing, sensing parameters, and battery status.

Long-Term Follow-Up

The schedule for long-term follow-up depends on several factors, including the type of pacemaker, the patient's clinical condition, and any complications that may have arisen. Generally, for single-chamber pacemakers, follow-up visits are recommended at 4-6 months initially, then annually until signs of battery depletion appear, at which point more frequent visits (every 3 months) are advised 1. For dual-chamber pacemakers, a 6-monthly follow-up schedule is preferred due to the potential need for adjustments in multiple programming parameters. Transtelephonic monitoring can also be valuable, especially for patients with limited mobility or those living far from follow-up centers, allowing for frequent assessment of the pacing system's performance and the opportunity to record cardiac rhythm during symptoms.

From the Research

Management of Patients after Pacemaker Placement

• The management of oral anticoagulation in patients undergoing pacemaker (PPM) or implantable cardioverter-defibrillator (ICD) implantation remains controversial 2.
• A randomized trial found that continuation of warfarin during PPM or ICD implantation may be safer compared to strategies requiring interruption and/or heparin bridging 2.
• The study found that among patients randomized to warfarin interruption, there were two pocket hematomas, one pericardial effusion, one transient ischemic attack, and one patient who developed heparin-induced thrombocytopenia, while no events were noted among patients continuing warfarin 2.

Anticoagulation Therapy

• The combined use of aspirin and oral anticoagulant therapy in patients with atrial fibrillation (AF) and stable coronary artery disease (CAD) has been questioned due to an increased risk of major bleeding with little to no benefit in preventing ischemic events 3.
• A literature review suggests that the use of combined antiplatelet and anticoagulant therapy may lead to increased major bleeding with little benefit in decreasing either AF-related stroke or cardiovascular events 3.
• Oral anticoagulants have been used in patients with vascular disease for over 40 years, yet their role in the secondary prevention of recurrent cardiovascular (CV) events remains controversial 4.

Coronary Artery Disease and Atrial Fibrillation

• For secondary prevention of coronary artery disease (CAD), oral antiplatelet therapy is essential, and in case of coronary intervention, temporary dual antiplatelet therapy is mandatory 5.
• Atrial fibrillation (AF) is often seen in CAD and vice versa, and in most patients, stroke prevention in AF consists of oral anticoagulation 5.
• The use of beta-blockers and calcium channel blockers in patients with stable coronary artery disease (SCAD) has been studied, and current evidence suggests that beta-blocker use as a first-line antianginal medication is associated with lower 5-year all-cause mortality only in patients who had MI within a year 6.