What are the management steps for electrical chest pain associated with a pacemaker (Portable Automatic Cardiac Electronic) or ICD (Implantable Cardioverter Defibrillator)?

Management of Electrical Chest Pain Associated with Pacemakers or ICDs

When a patient presents with electrical chest pain associated with a pacemaker or ICD, immediate device interrogation by a cardiologist or pacemaker specialist is essential to identify and address the underlying cause. 1

Initial Assessment

• Check vital signs: Monitor for bradycardia, tachycardia, hypotension, or signs of hemodynamic instability
• Obtain 12-lead ECG: Look for pacing spikes, capture failures, sensing issues, or arrhythmias
• Assess device site: Examine for signs of infection, hematoma, erosion, or migration
• Determine device type and dependency: Identify if patient is pacemaker-dependent

Immediate Management Steps

1. Device Interrogation

   • Consult cardiology or pacemaker service for comprehensive device evaluation 1, 2
   • Check for inappropriate sensing, pacing thresholds, lead impedance, and recorded events
   • Evaluate for electromagnetic interference (EMI) as potential cause

2. Temporary Measures While Awaiting Specialist

   • For hemodynamically unstable bradyarrhythmias, consider percussion pacing until electrical pacing is available 1
   • Have external defibrillator immediately available with pads positioned at least 8 cm from device generator 1

3. Management Based on Findings

   For lead-related issues:

   • Dislodgement: Urgent lead repositioning may be required
   • Fracture: Lead replacement by electrophysiologist
   • High thresholds: Reprogramming or lead revision

   For generator-related issues:

   • Battery depletion: Urgent generator replacement
   • Pocket infection: Antibiotics and complete system extraction 3
   • Generator malfunction: Replacement and reporting to manufacturer 4

   For EMI-related issues:

   • Identify and eliminate source of interference
   • Reprogram device to minimize susceptibility to EMI 1, 5
   • Advise patient to avoid identified EMI sources

Special Considerations

• For patients requiring surgery:

  • Reprogram pacing function to asynchronous mode
  • Disable rate-responsive functions and suspend antitachyarrhythmia functions
  • Position electrosurgical receiving plate away from generator and leads
  • Use bipolar electrocautery or ultrasonic scalpel when possible 1, 2

• For pacemaker-dependent patients:

  • More aggressive management is warranted
  • Consider temporary pacing if device function is compromised
  • Program to asynchronous mode (VOO, DOO) if EMI is anticipated 1, 2

Post-Resolution Follow-up

• Interrogate device to ensure proper function and restore all settings
• Monitor cardiac rhythm continuously until stable device function is confirmed
• Schedule follow-up device check within 1-2 weeks
• Educate patient on warning signs requiring immediate attention
• Consider more frequent follow-up intervals (less than 6 months) if device issues identified 1

Common Pitfalls to Avoid

• Misdiagnosing device-related chest pain as acute coronary syndrome: Device-related pain can mimic cardiac ischemia 6
• Failure to recognize EMI as a cause: Various electronic devices can interfere with pacemaker/ICD function 5
• Inadequate device interrogation: Complete device evaluation is essential, not just basic checks
• Delayed specialist consultation: Early involvement of electrophysiology is crucial for optimal outcomes
• Overlooking lead or pocket infection: Can present subtly but requires aggressive management 3

By following this structured approach, clinicians can effectively manage electrical chest pain associated with cardiac implantable electronic devices while minimizing risks of serious complications.