What should be checked during a pacemaker check-up in an older adult patient with a history of cardiovascular disease?

Pacemaker Check-Up Components

A comprehensive pacemaker check-up should include device interrogation with assessment of battery status, lead function (impedance and thresholds), pacing/sensing parameters, stored diagnostic data review, underlying rhythm assessment, and evaluation for arrhythmias—all integrated with a targeted cardiovascular clinical assessment.

Essential Technical Assessments

Device Interrogation and System Testing

• Interrogate the pacing system to retrieve all telemetered data, including battery voltage, current drain, and estimated longevity 1
• Measure lead impedance for both atrial and ventricular leads to detect early signs of lead insulation break, fracture, or dislodgement 2
• Assess pacing thresholds (capture thresholds) for all leads to ensure adequate safety margins and optimize battery longevity 1
• Test sensing thresholds to identify oversensing or undersensing problems that may cause inappropriate device function 2

Stored Diagnostic Data Review

• Review stored intracardiac electrograms (EGMs) if available, as these provide crucial information about arrhythmias that occurred between visits, whether symptomatic or asymptomatic 2
• Analyze pacemaker activity counters including percentage of atrial and ventricular pacing, mode switching episodes, and total pacing burden 3
• Check for stored arrhythmia episodes, particularly atrial fibrillation/flutter and ventricular tachyarrhythmias, as detection of these may require anticoagulation or antiarrhythmic therapy changes 2
• Evaluate battery cell impedance trends graphically to recognize end-of-life parameters or suspected malfunction 4

Underlying Rhythm Assessment

• Assess the patient's intrinsic cardiac rhythm by temporarily programming the pacemaker to subthreshold output or reducing the pacing rate below the patient's intrinsic rate 1
• Document any changes in underlying rhythm since the previous visit, as this may necessitate reprogramming 1

Clinical Assessment Components

Targeted Cardiovascular Evaluation

• Obtain focused cardiovascular history specifically addressing syncope, near-syncope, palpitations, new or worsening dyspnea, unexplained fatigue, or changes in exercise tolerance 5
• Perform physical examination focusing on volume status, signs of heart failure, and assessment for new murmurs or arrhythmias 5
• Review any interval cardiovascular events including hospitalizations, new medications (particularly antiarrhythmics), or changes in cardiac status 1

Special Considerations for Older Adults with Cardiovascular Disease

For patients with congenital heart disease and pacemakers, regular echocardiographic monitoring is essential, particularly in those with congenitally corrected transposition (CCTGA), due to risk of worsening systemic AV valve regurgitation with ventricular pacing 5

In patients with biventricular pacemakers (CRT devices), ensure delivery of 100% biventricular stimulation, as loss of CRT due to atrial tachyarrhythmias is a common cause of heart failure hospitalization 5

Programming Optimization

• Reprogram pacing parameters as needed to optimize device function and maximize battery longevity based on threshold measurements 1
• Adjust AV delay settings in dual-chamber or CRT devices to optimize ventricular filling, particularly important in older adults with reduced ventricular compliance 5
• Enable or adjust rate-responsive features if the patient has chronotropic incompetence and reduced exercise capacity 5
• Program appropriate mode switching for patients at risk of atrial tachyarrhythmias to prevent rapid ventricular pacing 5

Follow-Up Timing and Frequency

Standard follow-up schedule should include assessment within 72 hours of implantation, at 2-12 weeks post-implant, at 6 months, and annually thereafter as a minimum 1

More frequent assessments (every 3-6 months) are warranted for patients with:

• Multiple cardiovascular comorbidities 1
• History of device complications 1
• Devices approaching end-of-life parameters 4
• Biventricular pacemakers or ICDs, which require coordination between heart failure and electrophysiology teams 5

Critical Pitfalls to Avoid

• Do not rely solely on transtelephonic monitoring—direct patient assessment is preferable as it allows for comprehensive clinical evaluation and hands-on device interrogation 1
• Do not overlook asymptomatic arrhythmias detected on stored diagnostics, as these may require anticoagulation or other interventions that can alter clinical outcomes 2
• Do not assume stable function without checking—lead impedance changes can occur suddenly, and early detection prevents more serious complications 2
• In patients with temporary pacemakers, continuous ECG monitoring is mandatory until the device is removed or replaced with a permanent system, as multiple failure modes can occur 5