Can a regular stress test be performed on a patient with a pacemaker (permanent artificial cardiac pacemaker)?

Can You Perform a Regular Stress Test on a Pacemaker Patient?

Yes, you can perform a regular stress test on a patient with a permanent pacemaker, and these patients should undergo stress testing using the same protocols as other cardiac patients, with specific considerations for pacemaker type and settings. 1

Exercise Stress Testing in Pacemaker Patients

Standard Exercise Testing is Feasible

• Patients with pacemakers can undergo standard exercise testing if performance during the test is satisfactory, though the approach must be modified based on pacemaker type and settings 1
• The type and settings of the pacemaker should be documented before testing, and exercise should be prescribed accordingly 1

Key Considerations by Pacemaker Type

Rate-Responsive Pacemakers:

• These devices can accelerate heart rate during exercise, allowing for more conventional stress testing 1
• Cardiopulmonary exercise testing (CPX) is increasingly used to evaluate and optimize rate-responsive pacemaker function 1
• CPX can help adjust rate-response settings and atrioventricular delay to maximize peak VO2, ventilatory threshold, and O2 pulse 1

Fixed-Rate (Non-Rate-Responsive) Pacemakers:

• Physical activity intensities must be gauged by methods other than pulse counting, such as defining specific workloads initially at 40-60% of peak exercise capacity as determined by baseline testing 1
• Rating of perceived exertion should be used instead of target heart rate for monitoring exercise intensity 1

Stress Echocardiography Options

Pacemaker-Specific Stress Testing

Noninvasive pacemaker stress echocardiography (PASE) is a validated alternative that can be performed by external programming of the permanent pacemaker 2, 3

• PASE demonstrated 70% sensitivity, 90% specificity, and 78% accuracy for detecting significant coronary artery disease in a multicenter study 2
• When abnormal wall motion at rest that remained unchanged at peak stress was considered positive, accuracy improved to 85% 2
• The test is performed using 10 beats/min increments up to ischemia or target heart rate, with average duration of 8.9 minutes 2
• No significant side effects were observed, making it a safe option 2

Standard Stress Imaging Modalities

Exercise or pharmacologic stress echocardiography can be performed with the same indications as non-pacemaker patients 1

• Exercise echocardiography is particularly useful when baseline ECG abnormalities obscure ischemic changes 1
• Pharmacologic stress testing with vasodilators (adenosine, dipyridamole) should NOT be used in patients with second- or third-degree AV block without permanent pacemakers, though this contraindication is obviated by the presence of a functioning pacemaker 1

Practical Testing Approach

Pacemaker-Dependent vs. Pacemaker-Independent Patients

• Pacemaker-independent patients (those who inhibit the pacemaker with their own rhythm) typically achieve higher metabolic equivalents (METs) and oxygen consumption during exercise testing 4
• Pacemaker-dependent patients (those with complete AV block) can still undergo stress testing but may have different exercise capacity 4
• Blood pressure response is similar between both groups 4

Exercise Protocol Selection

• Standard Bruce protocol can be used in pacemaker patients 4
• For patients unable to exercise due to deconditioning, peripheral vascular disease, orthopedic disabilities, or neurological disease, pharmacologic stress testing is appropriate 1

Common Pitfalls to Avoid

Do not assume pacemaker patients cannot undergo standard exercise testing - most can participate with appropriate modifications 1

Do not rely solely on heart rate for exercise prescription in fixed-rate pacemakers - use workload-based targets and perceived exertion instead 1

Do not overlook the opportunity to use the pacemaker itself as the stress modality - noninvasive PASE can be the first-line stress test in patients with permanent pacemakers due to its safety and ease of repeatability 3

Ensure adequate heart rate achievement - four of eight false-negative PASE results occurred in patients who did not reach target heart rate 2