From the Guidelines
In asymptomatic patients with a pacemaker, discontinuation of pacemaker therapy is reasonable after evaluation of symptoms during a period of monitoring while pacing therapy is off, as stated in the 2018 ACC/AHA/HRS guideline 1. The management of pacemakers in asymptomatic patients involves a thorough evaluation to determine if the original pacing indication has resolved or is in question.
- According to the 2018 ACC/AHA/HRS guideline, discontinuation of pacemaker therapy can be considered in patients who present for pacemaker pulse generator replacement or for management of pacemaker-related complications, in whom the original pacing indication has resolved or is in question 1.
- A study published in the Journal of the American College of Cardiology found that in patients who underwent pacemaker removal, none had symptomatic bradycardia after 18 to 48 months of follow-up, suggesting that discontinuation of pacemaker therapy can be safe in selected patients 1.
- The decision to discontinue pacemaker therapy should be made on a case-by-case basis, taking into account the individual patient's symptoms, medical history, and underlying cardiac condition.
- It is essential to evaluate symptoms during a period of monitoring while pacing therapy is off to determine if the patient can tolerate the discontinuation of pacemaker therapy 1.
- The protocol for discontinuing pacing therapy may include clinical evaluation, echocardiogram, exercise testing, and tilt table testing, as well as periodic 24-hour ambulatory electrocardiographic monitoring for up to 1 year, after which an electrophysiology study (EPS) can be conducted 1.
From the Research
Management of Pacemaker in Asymptomatic Patients
The management of pacemakers in asymptomatic patients involves regular follow-up and monitoring to ensure the proper functioning of the device. Key aspects of this management include:
- Regular interrogation and basic programming of the pacemaker to evaluate its functioning and adapt it to the patient's needs 2
- Remote monitoring of the pacemaker to detect clinically actionable events earlier and more frequently than traditional transtelephonic monitoring 3
- Use of ambulatory 24-hour Holter monitoring to detect asymptomatic pacemaker malfunction episodes, such as failure to pace or sense, and to reprogram the pacemaker parameters if necessary 4
Considerations for Asymptomatic Patients with Pacemakers
Asymptomatic patients with pacemakers should be aware of the potential risks and precautions associated with their device, including:
- Electromagnetic interference (EMI) from certain medical procedures, such as MRIs, electrosurgical cutters, or radiotherapy 5
- The risk of explosion during cremation if the pacemaker is not removed after death 5
- Potential limitations on certain professions or activities due to the presence of a pacemaker 5
Detection and Evaluation of Asymptomatic Atrial Fibrillation
Asymptomatic atrial fibrillation (AF) is common in patients with pacemakers and may have significant prognostic implications. Studies such as the ASSERT trial aim to evaluate the detection of asymptomatic AF using pacemaker telemetry and its association with an increased risk of stroke and other vascular events 6