Will a pacemaker improve outcomes in a 70-year-old male with triple heart block, brachycardia, and recent myocardial infarction, who is bed-bound and on a liquid diet?

From the Guidelines

A pacemaker is strongly recommended for this 70-year-old male with triple heart block, bradycardia, and recent myocardial infarction, even considering his bed-bound status and liquid diet. The patient's condition, characterized by triple heart block and bradycardia following a myocardial infarction, indicates a high risk of sudden cardiac death and worsening heart failure if left untreated 1. Permanent pacemaker implantation is the definitive treatment for complete heart block, particularly when accompanied by symptomatic bradycardia, and would likely improve his cardiac output, hemodynamic stability, and potentially allow for improved mobility and quality of life.

Key considerations in this patient's management include:

• The presence of symptomatic heart block, which necessitates pacing according to guidelines 1
• The need for a thorough cardiac evaluation, including echocardiography to assess ventricular function, before pacemaker implantation
• Normalization of electrolyte levels before the procedure
• The potential benefits of pacing in improving cardiac output and reducing the risk of sudden cardiac death and heart failure progression

The patient's prognosis without a pacemaker is poor, with significant risks of sudden cardiac death, worsening heart failure, and continued poor perfusion 1. In contrast, pacemaker implantation has been shown to improve survival in patients with third-degree AV block, especially if syncope has occurred. While there are risks associated with pacemaker implantation, including infection, lead displacement, and bleeding, these are generally outweighed by the substantial benefits in a patient with this cardiac profile.

Given the most recent and highest quality evidence, the recommendation for pacemaker implantation in this patient is clear and should be prioritized to improve his morbidity, mortality, and quality of life 1.

From the Research

Pacemaker Implantation

• A pacemaker can help improve outcomes in a 70-year-old male with triple heart block, brachycardia, and recent myocardial infarction by regulating his heart rhythm and preventing further complications 2, 3.
• The decision to implant a pacemaker should be based on the patient's overall health, the severity of his heart block, and his response to other treatments 4, 5.

Prognosis

• The prognosis for a patient with triple heart block, brachycardia, and recent myocardial infarction is generally poor, with a higher risk of mortality and hemodynamic complications 5, 6.
• The presence of atrioventricular block in acute inferior wall myocardial infarction is related to the presence of an important right coronary artery that is occluded, and recanalisation of this vessel can lead to rapid regression of the block 5.
• Thrombolytic therapy may improve the outcome of patients with atrioventricular block complicating acute myocardial infarction, but its effect on the incidence of atrioventricular block is unclear 5, 6.

Management

• Effective management of triple heart block, brachycardia, and recent myocardial infarction includes accurate interpretation of a 12-lead EKG, assessment of hemodynamic stability and systemic perfusion, and time-sensitive pharmacologic or procedural intervention 2.
• Patients with triple heart block and recent myocardial infarction should be closely monitored for signs and symptoms of bradycardia or higher degree atrioventricular block, and anti-thrombotic prophylaxis may be beneficial in certain cases 4.