Tachycardia Mechanisms and Management in Pacemaker Patients

The American Heart Association notes that pacemaker-mediated tachycardia, underlying arrhythmias, or intentional programming of the pacemaker can cause tachycardia in patients with pacemakers 1, 2

Pacemaker Types and Tachycardia Relationship

Rate-responsive pacemakers, such as VVIR, DDIR, and DDDR, can increase heart rate in response to physical activity, and are useful in patients with chronotropic incompetence, as recommended by the American College of Cardiology 1, 3
DDD pacemakers can track rapid atrial rates and conduct them to the ventricles, potentially causing tachycardia, according to the European Society of Cardiology 1, 2

Antitachycardia pacing can detect and terminate tachyarrhythmias by delivering rapid pacing sequences, as suggested by the American Heart Association 4
Programming appropriate upper rate limits, setting post-ventricular atrial refractory periods, and using mode-switching algorithms can prevent pacemaker-mediated tachycardia, as recommended by the European Heart Rhythm Association 1, 2
Patients with accessory pathways capable of rapid antegrade conduction should not receive certain types of pacemakers due to risk of dangerous tachyarrhythmias, according to the American College of Cardiology 4

The American College of Cardiology notes that patients with accessory pathways capable of rapid anterograde conduction should not receive atrial-tracking pacemakers due to the risk of life-threatening tachyarrhythmias 5

The American College of Cardiology recommends extending the post-ventricular atrial refractory period (PVARP) to prevent sensing of retrograde P waves, although this limits the maximum tracking rate, and notes that automatic PMT termination algorithms can detect repetitive VA patterns and extend PVARP to break the circuit 5