Assessment of pacemaker chronotropic response: implementation of the Wilkoff mathematical model

There are few practical guidelines for proper adjustment of rate responsive pacemaker sensor parameters. This study describes the application of the chronotropic assessment exercise protocol (CAEP) and the Wilkoff model of chronotropic response to assess the adjustment of pacemaker sensor parameters. In 31 patients implanted 1 month previously with a dual sensor pacemaker, pacemaker sensor parameters were adjusted to yield a peak sensor rate of 100 beats/min on a simple 6-minute walk (low intensity treadmill exercise [LITE] protocol); the maximum sensor rate was set to the age predicted maximum heart rate (220-age). The rate response behavior of the pacemaker was then assessed using the slope of metabolic-chronotropic relation (MCR) during CAEP exercise. After adjustments based on the LITE protocol, CAEP exercise yielded MCR slopes of 0.92 +/- 0.25 for the entire study group, which compares well with the predicted normal slope of 1. However, 7 of the 31 patients had sensor MCR slopes during CAEP exercise that were 2 SD or more below expected. To test the sensitivity of this approach to suboptimal pacemaker programming or suboptimal exercise, simulations were performed with the maximum sensor rate programmed below age-predicted maximum heart rate or with exercise truncated before maximum exertion; with these conditions, MCR slopes were sharply lower for the entire group. The authors conclude that a simple treadmill walk (LITE) allowed for optimum programming of sensor parameters in most patients, but in a minority the chronotropic behavior was underresponsive. Failure to appropriately adjust pacemaker maximum sensor rate or failure to achieve peak exercise sharply limits the accuracy of this methodology.