Will a pacemaker help a 70-year-old male with triple heart block and bradycardia who had a massive myocardial infarction (MI) and is currently bed-bound on a liquid diet?

From the Guidelines

A pacemaker is likely to benefit this 70-year-old male with triple heart block and bradycardia following a massive myocardial infarction, as it provides reliable heart rate control and can prevent potentially life-threatening pauses or extreme bradycardia. According to the 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay 1, permanent pacing is recommended for patients with acquired third-degree atrioventricular block not caused by reversible or physiologic causes, regardless of symptoms.

The patient's current condition, including being bed-bound and on a liquid diet, suggests significant cardiac damage and possible complications, making heart rate stabilization crucial. However, the overall prognosis and benefit must be carefully evaluated considering the extensive cardiac damage from the massive MI, the patient's age, and his current functional status.

Some key points to consider in the management of this patient include:

• The use of temporary transvenous pacemaker initially while assessing recovery potential from the MI, followed by permanent pacemaker implantation if indicated 1
• The importance of a comprehensive cardiac assessment, including echocardiography to evaluate ejection fraction and remaining viable myocardium, before proceeding with permanent pacemaker implantation 1
• The consideration of techniques that provide more physiologic ventricular activation, such as cardiac resynchronization therapy or His bundle pacing, if the patient has an indication for permanent pacing and is expected to require ventricular pacing >40% of the time 1

It is essential to weigh the potential benefits of pacemaker implantation against the risks and consider the patient's goals of care and preferences, as emphasized in the 2018 ACC/AHA/HRS guideline 1. Ultimately, the decision to implant a pacemaker should be made on a case-by-case basis, taking into account the individual patient's circumstances and the latest available evidence.

From the Research

Pacemaker Therapy for Triple Heart Block and Bradycardia

• A pacemaker can help a 70-year-old male with triple heart block and bradycardia by treating the bradycardia and improving his heart rate, as stated in the study 2.
• The patient's condition of having a massive myocardial infarction (MI) and being bed-bound on a liquid diet may affect his prognosis, but pacemaker therapy can still be beneficial in managing his bradycardia, as discussed in 3.

Prognosis and Survival

• The prognosis for a 70-year-old male with triple heart block, bradycardia, and a massive MI is generally poor, but pacemaker therapy can improve his survival and quality of life, as shown in the study 4.
• The study 4 found that the 5-year survival rate for patients aged ≥ 85 years who received pacemaker implantation was 45%, and the 8-year survival rate was 26%.
• The risk of death was associated with non-cardiac factors such as higher age, lower ejection fraction, dementia/dysautonomia, and diagnosis of cancer, as reported in 4.

Management and Treatment

• The management of bradycardia involves evaluating the patient's symptoms and treating the underlying cause, as discussed in the study 5.
• Pacemaker therapy is a clinically effective therapeutic option to improve survival and control bradyarrhythmia-related symptoms in very elderly patients, as stated in 4.
• The study 6 explains the principles of cardiac pacing, interventions, and patient support, highlighting the importance of proper management and follow-up care for patients with pacemakers.