Permanent Cardiac Pacing in the Elderly Patient: Is Selection of the Pacing Mode Important?

Most pacemaker recipients are elderly, and advanced age does not constitute a contraindication to the implantation of a permanent pacemaker. However, pacing in the older patient should no longer be regarded simply as a way to prevent Stokes-Adams attacks or life-threatening bradyarrhythmia. A VVI pacemaker for everyone is now inappropriate, especially in active and otherwise healthy older patients. Selection of the optimal devise or pacing mode in older patients requires an understanding of how aging affects the cardiovascular system (left ventricular diastolic dysfunction) and the natural history of disease, especially sick sinus syndrome after pacemaker implantation. Many retrospective and nonrandomized studies focusing mostly on the sick sinus syndrome have indicated that atrial-based pacing improves the quality and duration of life when compared to single lead ventricle pacing. The lower incidence of chronic atrial fibrillation in patients with atrial-based pacemakers compared to VVI devices is of great importance in the elderly, in whom this arrhythmia is associated with greater morbidity and mortality than in younger individuals. The decreased mortality associated with atrial-based pacing compared to single lead ventricular pacing seems to favor patients older than 70 years. There is now a growing realization that implantation of dual chamber pacemakers in the elderly is cost-effective on a long-term basis by avoiding or reducing the complications associated with single lead ventricular pacing, thereby reducing the need for repeated hospitalizations and medical care.