Common pitfalls in interpreting pacemaker electrocardiograms in the emergency department

The number of patients receiving pacemakers and defibrillators has grown substantially over the last 20 years. In addition, the complexity and sophistication of these devices have increased, making diagnosis of pacemaker problems using the electrocardiogram (ECG) more difficult for clinicians in the emergency department. This article will focus on a few of the pitfalls to be avoided when interpreting paced ECGs. Pacemaker algorithms designed to minimize right ventricular pacing may be confused with pathologic failure to output. Automatic capture threshold detection schemes may be misinterpreted as failure to capture as well as undersensing due to the extra "backup" pacemaker spikes noted on rhythm strips. Device testing done in the emergency department may produce waveforms on monitor resembling ventricular tachycardia if pacemaker-mediated tachycardia is produced accidentally. Ventricular safety pacing algorithms may also be misinterpreted as failure to sense appropriately, triggering questions about pacemaker malfunction. Certain types of true undersensing may resemble morphologies consistent with pacemaker lead dislodgment. In addition, sophisticated programming features designed to mimic normal physiology could be misconstrued as pacemaker malfunction. These include pacemaker hysteresis and sleep mode. The presence of frequent premature ventricular complexes would cause a pacemaker to inhibit ventricular pacing appropriately. However, this could produce a palpated heart rate that is substantially lower than the programmed lower rate of the device due to reduced perfusion by the premature ventricular complexes, again raising questions about the appropriate functioning of the pacemaker. All of these situations will be discussed in detail along with approaches to systematically examining the paced ECGs to minimize the risk of misinterpretation. Pacemaker timing cycles as they relate to troubleshooting of the paced ECG will also be introduced.