Pacemaker Therapy for Bradycardia and Premature Ventricular Contractions

Introduction to Pacemaker Therapy

The American College of Cardiology notes that inappropriate pacing modes can lead to pacemaker syndrome with symptoms including light-headedness or syncope related to AV dyssynchrony 1
The American College of Cardiology, American Heart Association, and Heart Rhythm Society recommend permanent pacemaker implantation for patients with atrial fibrillation who experience third-degree and advanced second-degree AV block at any anatomic level in awake, free patients with AF and bradycardia with 1 or more pauses of at least 5 seconds or longer, which is a Class IIa recommendation 2
A conversion pause of 7 seconds or longer meets the Class IIa recommendation for pacing in patients with AF and bradycardia with pauses of at least 5 seconds or longer, as stated by the American College of Cardiology 2

Dual-chamber pacing is preferable over single-chamber ventricular pacing to preserve AV synchrony during sinus rhythm and provide rate modulation in response to sudden drops in heart rate, according to the American College of Cardiology and the American Academy of Family Physicians 3, 4
When selecting a pacemaker for patients with bradycardia and problematic PVCs, consider dual-chamber pacing, rate-responsive features, and programmable lower rate limits 3, 4

Pacing-induced proarrhythmia can occur in some cases, where ventricular pacing itself can promote arrhythmias through altered activation sequences
Failure to recognize underlying causes of PVCs, such as structural heart disease, electrolyte abnormalities, or medication effects, is a consideration in pacemaker therapy
The American College of Cardiology recommends ruling out reversible causes of bradycardia, such as electrolyte abnormalities, drug effects, and transient inflammation or vagal responses, before permanent pacemaker implantation 2

Regular device follow-up is necessary to assess percentage of pacing and AF burden, and optimization of rate-response settings based on patient activity levels is recommended, with consideration of anticoagulation assessment based on CHA₂DS₂-VASc score, as suggested by the American College of Cardiology and other guideline societies 5