Cardiac pacing: principles, interventions and patient support
Intended for healthcare professionals
CPD    

Cardiac pacing: principles, interventions and patient support

Kay Elliott Arrhythmia nurse specialist, Dorset County Hospital NHS Foundation Trust, Dorchester, England

Why you should read this article:
  • To refresh your knowledge of cardiac pacing principles and interventions

  • To understand the role of the nurse in the management of patients receiving cardiac pacing

  • To count towards revalidation as part of your 35 hours of CPD, or you may wish to write a reflective account (UK readers)

  • To contribute towards your professional development and local registration renewal requirements (non-UK readers)

Cardiac pacing is used to treat a variety of heart rhythm irregularities or arrhythmias, most commonly bradyarrhythmia, which is characterised by an abnormally slow heart rate. Temporary and permanent pacemakers work by sending intermittent electric impulses to the heart muscle, stimulating it to contract and ensuring a steady heart rate. This article explains the various temporary and permanent cardiac pacing interventions, describes how pacemakers work, outlines the complications that can arise from their use and details the needs of patients in terms of information, support, monitoring and follow-up.

Nursing Standard. doi: 10.7748/ns.2022.e11881

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Correspondence

kay.elliott@dchft.nhs.uk

Conflict of interest

None declared

Elliott K (2022) Cardiac pacing: principles, interventions and patient support. Nursing Standard. doi: 10.7748/ns.2022.e11881

Published online: 31 January 2022

Aims and intended learning outcomes

The aim of this article is to support nurses to enhance their knowledge of the principles of cardiac pacing, of temporary and permanent cardiac pacing interventions, and of the nursing management of patients who receive cardiac pacing. After reading this article and completing the time out activities you should be able to:

  • Explain how cardiac pacing works and the rationale for its use.

  • List the indications for different cardiac pacing interventions.

  • Contrast and compare temporary and permanent cardiac pacing methods.

  • List the potential complications associated with the use of temporary and permanent pacemakers.

  • Describe the education and support needs of patients who receive cardiac pacing.

Key points

  • Cardiac pacing sends electric impulses to the heart, prompting it to contract and ensuring a steady heart rate, when the heart is no longer able to do this by itself

  • Cardiac pacing is used to treat heart rhythm irregularities, particularly bradyarrhythmia, which is characterised by an abnormally slow heart rate

  • Temporary pacing is notably used to treat sudden and extreme bradyarrhythmia until a permanent pacemaker can be implanted or the need for pacing is resolved. Temporary pacing is sometimes used prophylactically, for example following cardiac surgery

  • Permanent cardiac pacing is used to reproduce cardiac conduction and prevent symptomatic bradyarrhythmia and/or pauses in the heartbeat

  • A permanent pacemaker consists of a box implanted subcutaneously in the infraclavicular area, which is connected to the heart chambers by pacing leads

  • Patients who receive cardiac pacing need close monitoring and follow-up to check for complications and adjust pacemaker settings

Introduction

Cardiac pacing involves stimulating the myocardium (heart muscle) to contract by applying a low-voltage intermittent electric current (Osborne 2017). In cardiac pacing, electric impulses are sent to the myocardium from an external generator (pacing unit) via wires called pacing leads. This ensures a steady heart rate in patients whose heart is no longer able to achieve this by itself.

The pacing unit and leads form a cardiac pacing system commonly known as a pacemaker. A pacemaker can be used temporarily, in which case the pacing unit is placed outside the patient’s body, or permanently, in which case the pacing unit is implanted within the patient’s body. Pacemakers have been used in one form or another since the 1950s. However, some of the temporary cardiac pacing interventions used in emergency situations – namely percussion pacing and transcutaneous pacing – do not involve a pacemaker. In fact, percussion pacing does not use electric impulses at all.

Cardiac pacing is used to treat arrhythmias (heart rhythm irregularities) and particularly bradyarrhythmias (abnormally slow heart rate, also called bradycardia). Bradyarrhythmias are generally characterised by a heart rate of <60 beats per minute. Bradyarrhythmias can be normal in some people during sleep and can be induced by medicines such as beta-blockers (Nolan et al 2016). However, bradyarrhythmias can also arise from the malfunctioning of the sinoatrial node (the heart’s primary ‘natural’ pacemaker) or of the atrioventricular conduction system (which incorporates the atrioventricular node and conducts electric impulses from the atria to the ventricles). People with a bradyarrhythmia caused by a malfunctioning of the sinoatrial node or the atrioventricular conduction system who experience, or are at risk of, consequent haemodynamic compromise and/or cardiac arrest are prime candidates for cardiac pacing (Nolan et al 2016).

This article examines the use of pacemakers in relation to bradyarrhythmia. This will include both temporary and permanent pacing options. The more complex pacing options of implantable cardioverter defibrillators (ICDs) and cardiac resynchronisation therapy (CRT) devices are beyond the scope of this article. There is ongoing research into leadless pacemakers (Eftekhari et al 2017, Glikson et al 2021), which are capsule-like devices implanted directly into the right ventricle of the heart (Ngo et al 2021), but these devices are beyond the scope of this article. In 2019-20, more than 40,000 cardiac rhythm management devices, including pacemakers, ICDs and CRT devices, were implanted in patients in the UK (Healthcare Quality Improvement Partnership 2021).

TIME OUT 1

Are you confident that you have an adequate working knowledge of cardiac pacing and pacemakers? Before you read on, write down what you know about cardiac pacing and pacemakers. Once you have read the article, revisit your notes to assess any gaps in your knowledge

Temporary cardiac pacing

Temporary cardiac pacing is used in emergency situations as a bridging measure, when it is not possible to immediately implant a permanent pacemaker, to treat sudden and extreme bradyarrhythmia, as well as in situations where the need for cardiac pacing is likely to be temporary (Sullivan et al 2016, Glikson et al 2021). Situations where there may be a temporary need for cardiac pacing include (Glikson et al 2021):

  • During or after cardiac surgery, for example aortic valve replacement.

  • Adverse effects of antiarrhythmics.

  • Exposure to poisoning and/or overdose.

  • Electrolyte disorder, myocardial ischaemia or myocarditis.

Standard temporary cardiac pacing interventions include percussion pacing, transcutaneous pacing, transvenous pacing and epicardial pacing.

Percussion pacing and transcutaneous pacing

Percussion pacing involves administering repeated rhythmic ‘thumps’ with the side of a closed fist on the left lower edge of the patient’s sternum. Transcutaneous pacing involves sending electric impulses through the patient’s chest via defibrillation pads. Both interventions are unreliable in that they are not always effective and likely to cause pain. Subsequently, the patient may require intravenous analgesia, sedation and close monitoring (Nolan et al 2016).

Transcutaneous pacing is indicated in cardiac arrest or peri-arrest situations. It can provide emergency pacemaker functionality while arrangements are being made to insert a temporary pacemaker – or where possible implant a permanent pacemaker. Patients with a sudden and extreme bradyarrhythmia that is not immediately reversible and is causing, or is likely to cause, haemodynamic compromise and/or syncope (fainting) require emergency transcutaneous pacing until transvenous pacing can be started. Percussion pacing is indicated if there is a delay in starting transcutaneous pacing (Nolan et al 2016).

Temporary transvenous pacing

Temporary transvenous pacing involves inserting pacing leads into the right ventricle and right atrium of the heart – or one pacing lead into the right ventricle only – and sending electric impulses to the myocardium from an external pacing unit. It is typically used in patients who are haemodynamically compromised due to bradyarrhythmia and/or heart block. There are several types of heart block – with primary causes such as myocardial infarction, ageing, fibrosis and valvular heart disease – but all essentially result in delayed electrical conduction through the myocardium (Riley 2007). Temporary transvenous pacing can also be used to assist in treating tachyarrhythmias (Barnett 2007), but pacing is not usually indicated in tachyarrhythmias unless there is a co-existing, or a risk of, significant bradyarrhythmia.

For temporary transvenous pacing, the leads are usually inserted via the neck into the right external jugular vein or the left subclavian vein, although the femoral vein is sometimes used (McNaughton 2013). The jugular approach is preferred because the subclavian approach carries a higher risk of pneumothorax, since the subclavian vein is near the upper part of the lung (Glikson et al 2021). The femoral approach may be chosen when rapid intervention is required, but is only suitable for short-term use, because the patient has to remain immobile since ambulation could cause the lead to become displaced (Glikson et al 2021).

The leads are commonly threaded through the venous system with the aid of fluoroscopy (Glikson et al 2021). If fluoroscopy is not available or not convenient, echocardiogram guidance can be used. The tip of the ventricular lead is placed in the endocardium (lining of the heart) at the apex of the right ventricle. The atrial lead must be placed at the right atrial appendage (Barnett 2007). An atrial lead is not always required, for example if the patient has atrial fibrillation or if the risks of introducing a second temporary lead are thought to outweigh the benefits.

Once inserted, the leads are connected to the pacing unit and the capture threshold is tested. The capture threshold is the minimum voltage required for the myocardium to contract – the term ‘capture’ is used in reference to the myocardium ‘capturing’ the external electric impulses. Capture appears on an electrocardiogram (ECG) as a spike before a P wave in atrial pacing and/or a spike before a widened QRS complex in ventricular pacing. As the voltage is gradually turned up on the pacing unit, the capture threshold is reached. The output of the pacing unit is usually set 2.5-3.0 times higher than the capture threshold; this enables capture to continue even if the lead is slightly displaced but avoids sending an unnecessary and potentially damaging amount of electricity to the myocardium (Barnett 2007).

A temporary transvenous pacemaker is capable of detecting the patient’s intrinsic atrial (P wave) and/or ventricular (R wave) electrical activity so that it can provide external electrical support as required. The term ‘sensitivity’ is used to refer to the pacemaker’s capacity to ‘sense’ the patient’s intrinsic electrical activity (Tsiperfal et al 2011). The pacemaker is usually set to a ‘demand’ pacing mode, rather than a ‘fixed’ or ‘continuous’ pacing mode, which means it will withhold sending electric impulses when it senses intrinsic electric activity in the patient (Eftekhari et al 2017).

The rate of complications resulting from temporary transvenous pacing has been variously estimated to be between 14% and 20% of cases (Gammage 2000) and between 10% and 60% of cases (Sullivan et al 2016). Potential complications include (Barnett 2007, McNaughton 2014):

  • Ventricular irritability leading to ventricular tachyarrhythmia.

  • Pneumothorax – usually seen when the subclavian approach has been used.

  • Rupture of major blood vessels.

  • Cardiac perforation.

  • Cardiac tamponade (compression of the heart by a build-up of fluid or blood).

  • Lead displacement due to patient movement leading to variable capture or loss of capture.

  • Infection.

  • Abdominal twitching due to stimulation of the phrenic nerve – which primarily supplies the diaphragm.

Epicardial pacing

Post-operative temporary pacing can be achieved by attaching epicardial leads directly to the heart’s surface when the chest cavity is opened during cardiac surgery. This can provide timely temporary pacing to treat any arrhythmias arising post-operatively (McNaughton 2014, Kiely et al 2020). The leads are fixed to the epicardium on the right atria, the right ventricle or both, with the external ends threaded out through the skin at the subxiphoid region, just below the xiphoid process of the sternum (Barnett 2007). If pacing is required during the post-operative period, the leads are ready to be connected to an external pacing unit. Potential complications of epicardial pacing include bleeding, cardiac tamponade and arrhythmia, but the incidence of complications is low. When there are complications, they often occur upon or after lead removal (McNaughton 2014).

In their cross-sectional study on epicardial pacing in patients undergoing cardiopulmonary bypass, Kiely et al (2020) found that 74% of the 164 patients who had had epicardial leads inserted during surgery did not require post-operative cardiac pacing. More research is needed to determine which patients are more likely to require pacing after cardiac surgery (Kiely et al 2020). Sullivan et al (2016) stated that 24% of patients who had undergone valve surgery (aortic or tricuspid) required a permanent pacemaker, versus 4% of patients who had undergone coronary artery bypass grafting. Exploring whether there is a similar trend regarding the need for temporary pacing after cardiac surgery could assist in identifying which patients are more likely to require epicardial pacing post-operatively.

Patient observation and monitoring

Patients who receive temporary cardiac pacing of any type require support and reassurance from a multidisciplinary specialist team, as well as close observation and monitoring to promote the early identification and treatment of potential complications (Palmer 2014, Sullivan et al 2016).

In patients receiving temporary transvenous pacing or epicardial pacing, to prevent lead displacement the external section of the leads should be secured at the entry site, which is usually done using a sterile, air-occlusive transparent dressing that leaves the entry site visible. The entry site should be kept clean and regularly observed for signs of infection such as redness or discharge. The patient should have their temperature recorded at least every four hours. Infection can present suddenly and be fatal, so signs of infection need to be detected and treated promptly (Barnett 2007, McNaughton 2014).

In patients receiving temporary transvenous pacing, a post-insertion chest X-ray is required to check whether the leads have been correctly placed and that there is no pneumothorax (collapsed lung caused by air leaking into the pleural space) or haemothorax (accumulation of blood in the chest cavity) (McNaughton 2014, Sullivan et al 2016). If the leads are not in the correct position, they will require repositioning. If a pneumothorax or haemothorax is present and the patient shows signs of clinical deterioration, a chest drain will need to be inserted (Julian et al 2000, McNaughton 2014).

In patients receiving temporary transvenous pacing or epicardial pacing, continuous ECG monitoring by a competent healthcare practitioner is required to identify any arrhythmias, loss of capture and/or sensitivity failure. Loss of capture appears on the ECG as a pacing spike that does not reach the capture threshold and create the expected ECG configuration, while sensitivity failure appears as inappropriate pacing spikes; for example, an atrial pacing spike after an intrinsic p-wave (McNaughton 2013). Loss of capture and sensitivity failure are frequent in temporary transvenous pacing, occurring in 37-43% of patients, and may indicate that the leads need to be repositioned or replaced (Sullivan et al 2016).

In patients receiving temporary transvenous pacing or epicardial pacing, a competent healthcare practitioner should also undertake a daily capture threshold test (Barnett 2007, Sullivan et al 2016) and test the pacemaker’s sensitivity – usually daily and/or after device changes, according to local policy. Issues with capture or sensitivity need to be resolved, for example by reprogramming the pacemaker or requesting repositioning or reinsertion of the leads.

In patients receiving temporary transvenous or epicardial pacing, signs of potential cardiac tamponade – which include chest pain, low voltage or unusually flattened complexes on a 12-lead ECG, arrhythmia and hypotension – need to be promptly recognised and acted upon (McNaughton 2013).

TIME OUT 2

Think about a patient you have cared for who experienced symptomatic bradyarrhythmia. What type of cardiac pacing intervention do you think that patient may have required and why?

Permanent cardiac pacing

Permanent cardiac pacing is usually achieved using a transvenous pacemaker – although leadless pacemakers are starting to be used (Healthcare Quality Improvement Partnership 2021). Permanent transvenous pacemakers have two aims: to prevent symptomatic bradyarrhythmia and/or pauses in the heartbeat, and reproduce as accurately as possible normal cardiac conduction (National Institute for Health and Care Excellence (NICE) 2014). Prime candidates for permanent pacemaker implantation include (NICE 2014, Glikson et al 2021):

  • Patients with sinus node disease that leads to symptomatic bradyarrhythmia and/or pauses in the heartbeat.

  • Patients with high atrioventricular heart block at risk of syncope or sudden cardiac death.

  • Patients with co-existing bradyarrhythmia and tachyarrhythmia, in whom cardiac pacing will manage the tachyarrhythmia without risking symptomatic bradyarrhythmia.

Permanent transvenous pacemakers

A permanent transvenous pacemaker consists of a small pacemaker box to which pacing leads are attached (Tsiperfal et al 2011). The pacemaker box houses the pacing unit, including a battery, circuitry and capacitor, within a casing usually made of titanium. Modern pacemaker boxes have the ability to store data and feature several programming options (Tsiperfal et al 2011). Permanent transvenous pacemakers are similar to temporary ones in many respects, including functionality such as capture threshold and sensitivity.

Permanent pacemakers use lithium batteries that provide a stable power supply and predictably deplete over approximately ten years (Eftekhari et al 2017). When the battery reaches the recommended replacement time – typically three months before complete depletion – the pacemaker box is extracted and a new one is implanted and connected to the existing leads. Technological advances have produced leads that remain functional for the patient’s lifetime (Tsiperfal et al 2011, Eftekhari et al 2017), but there is always a risk of lead displacement or fracture, in which case the leads need to be repositioned or replaced (Eftekhari et al 2017).

Permanent pacemaker implantation

Permanent pacemakers are implanted electively or as part of an inpatient stay, depending on the severity of the patient’s symptoms and the risk of syncope and/or haemodynamic compromise. They are implanted using aseptic technique, usually in a setting that provides normal operating room standards and is equipped for fluoroscopy to guide lead insertion (Tsiperfal et al 2011). The procedure is generally undertaken with local anaesthetic, sedation and analgesia with single dose, pre-operative systemic antibiotic prophylaxis (Tsiperfal et al 2011, Glikson et al 2021).

The atrial lead is positioned in the right atrial appendage and the ventricular lead is positioned in the apex of the right ventricle, via either the subclavian vein or the cephalic vein (Barnett 2007). The distal ends of the leads are attached to the myocardium using active fixation with a small screw or passive fixation with small fins (Eftekhari et al 2017). The proximal ends of the leads are connected to the pacemaker box, which is usually placed in a subcutaneous ‘pocket’ surgically created in the infraclavicular area (below the clavicle), anterior to the pectoralis major muscle and contralateral to the patient’s dominant arm (Tsiperfal et al 2011).

A permanent pacemaker can be a single-lead ventricular pacemaker or a single-lead atrial pacemaker, but a dual chamber pacemaker – with an atrial and a ventricular lead – is usually recommended (NICE 2014). A single-lead ventricular pacemaker might be favoured in those with permanent atrial fibrillation or where concerns over co-morbidities and/or frailty have indicated that the risks of implanting a second lead outweigh the benefits (NICE 2014). In permanent atrial fibrillation, the atria fibrillate because of multiple and chaotic electric impulses, which additional atrial-paced beats would not improve.

After permanent pacemaker implantation, patients should undergo a pacing check, ideally within the first 24 hours and definitely within the first 72 hours of implantation, as per the British Heart Rhythm Society (BHRS) (2020) guidelines.

Permanent pacemaker programming

Permanent pacemakers feature several settings and pacing modes that can be programmed by a cardiologist and/or cardiac physiologist according to the patient’s needs. Pacemakers are usually programmed to ensure that the patient’s heart rate does not fall below a certain base rate. If the patient’s heart reaches that base rate, the pacemaker is activated (Tsiperfal et al 2011).

Rate modulation, also known as rate response, refers to cardiac pacing that is programmed to be responsive to the patient’s level of physical activity. In rate-modulation pacing, an embedded sensor detects increased levels of physical activity and the pacemaker responds by increasing the pacing rate, resulting in increased cardiac output and thereby increasing oxygen supply to support increased physical activity (Eftekhari 2017).

The various settings and pacing modes are described by single letters denoting, among other things, the chamber being paced, the chamber being sensed, the expected device response to sensing, and rate modulation (NICE 2014). For example, a patient with permanent atrial fibrillation fitted with a single-lead ventricular pacemaker would likely have their pacemaker set as VVIR:

  • V: ventricular pacing.

  • V: ventricular sensing.

  • I: inhibition response – that is, the pacemaker will not send electric impulses if it senses intrinsic ventricular electrical activity.

  • R: rate modulation.

TIME OUT 3

One of your patients is scheduled to have a pacemaker implanted electively. How would you explain to them what pacemakers are, how they work and what complications may arise from their use?

Permanent pacemaker complications

The risk of serious complications after permanent pacemaker implantation ranges from 8-12% in the first 90 days, nearly half of these complications being related to the leads or pacing unit. In the longer term, there is an annual 1-2% risk of complications, mainly attributable to infection or to lead failure (Ngo et al 2021). Close patient monitoring is required to detect and treat complications as they arise, before and after discharge.

Immediate complications of permanent pacemaker implantation include haematomas around the pacemaker pocket – particularly if the patient is taking dual antiplatelet therapy or anticoagulants – and lead displacement (Tsiperfal et al 2011, Palmer 2014). A post-procedural chest X-ray is required to check that the leads are correctly positioned and that there is no pneumothorax or haemothorax. For anatomical reasons, using the cephalic approach to place permanent pacing leads reduces the risk of pneumothorax and haemothorax, which can be as high as 2% when the subclavian approach is used (Tsiperfal et al 2011). In a pneumothorax, air can still move in and out of the pleural space. In a tension pneumothorax, air gets trapped inside the pleural space and compresses the lungs, heart and blood vessels. A tension pneumothorax is a rare life-threatening emergency that warrants immediate percutaneous pleural space decompression.

Pocket haematomas increase the risk of infection and an infected pacemaker can lead to significant healthcare expenses, morbidity and mortality (Glikson et al 2021). The risk of infection increases with each subsequent invasive procedure. Further invasive procedures will be required if the leads need to be repositioned or replaced, and when the pacemaker itself needs replacing because the battery is approaching depletion (Glikson et al 2021).

A relatively common complication of permanent pacemaker implantation is hypotension, which may be caused by cardiac tamponade or more commonly by dehydration or sedation (Tsiperfal et al 2011). If hypotension due to cardiac tamponade is suspected, an urgent ECG is needed to confirm this and guide pericardial catheter drainage if required. If pericardial catheter drainage is not possible or unsuccessful, the patient may require corrective heart surgery (Tsiperfal et al 2011).

Ongoing complications of permanent pacemaker implantation include venous occlusion and thrombosis, device or lead infection or erosion, lead displacement or fracture, and pacemaker syndrome – which manifests as fatigue, dizziness and hypotension, and can be caused by simultaneous atrial and ventricular contraction (Tsiperfal et al 2011, Palmer 2014, Glikson et al 2021). Device or lead erosion, lead fracture and pacemaker syndrome are less common in the early post-procedural stages than later on in the lifetime of the pacemaker. The risk of infection is present in the early post-procedural stages and in the longer term.

TIME OUT 4

What resources are available in your clinical area to support patients who have a pacemaker implanted? Are further resources needed locally? If so, what arguments would you use to advocate for further resources?

Patient education and support

Before discharge, patients should receive verbal and written advice regarding what to expect during the recovery period and how to reduce the risk of lead displacement. Advice on how to reduce the risk of lead displacement includes limiting extreme arm movements and heavy lifting on the side where the pacemaker box has been implanted – typically, but not always, on the left-hand side – for the first four to six weeks. Patients should also receive advice on how to look after the implantation site, how to report any wound issues and how to access assistance if they develop adverse effects such as chest pain or breathlessness (Nelson et al 2016).

Providing person-centred education and support is an integral component of the decision-making and consent processes and should therefore begin before pacemaker implantation. It should also continue after discharge, notably at regular and ongoing pacemaker reviews (Glikson et al 2021). Lifestyle advice, for example regarding work, driving and exercise, should be individualised, taking into account the indication for pacemaker implantation, the pacemaker model and the type of activities the patient wishes to undertake.

The arrhythmia team – which will include a cardiologist, a cardiac physiologist and cardiac nurses – at the centre where the pacemaker has been implanted can assist with outstanding questions. If there are concerns about whether electromagnetic fields emitted by workplace and/or medical equipment could cause interference, advice can be offered and technical checks can be undertaken. Patients can also be signposted to the information and support about living with a pacemaker that are available from charities such as Arrhythmia Alliance UK (www.arrhythmiaalliance.org.uk) and the British Heart Foundation (www.bhf.org.uk/informationsupport/treatments/pacemakers).

Table 1 summarises important education and support interventions that patients receiving a permanent pacemaker need to be provided with at different stages.

Table 1.

Education and support interventions for patients receiving a permanent pacemaker

Stage Area Interventions
Before pacemaker implantationPhysiological, medical and technicalProvision of information about the patient’s condition, indication for pacemaker implantation, pacemaker functioning, implantation process, recovery period and potential complications
EthicalProvision of impartial information and empathetic support to assist the patient in the decision-making and consent processes
Ongoing and/or as neededWork-relatedProvision of information on employment restrictions, for example because of electromagnetic interferences with work equipment
FinancialProvision of information on the cost of treatment, what is covered by the healthcare system, insurance and sick leave
Emotional and psychologicalAddressing potential patient anxieties and concerns, for example about body image and loss of function
Before and/or after dischargePractical Provision of a pacemaker identification card containing details of the pacemaker model, pacemaker leads and contact details of the pacemaker clinic
Provision of information on ongoing regular pacemaker reviews
Signposting to further reliable sources of information and support
Provision of information on further support options such as telephone-based support, face-to-face group sessions, patient forums and peer-support groups
Physiological and medical Educating the patient to recognise post-operative signs and symptoms – such as pain, stiffness in the shoulder and swelling and/or tenderness around the pacemaker pocket – when and how to undertake self-care and when and how to seek medical advice
Educating the patient about wound care and medicines use
Functional and work-relatedProvision of information on how the pacemaker may affect mobility, work, physical activities, having sex, driving and travelling

(Adapted from Glikson et al 2021)

TIME OUT 5

You are caring for a patient who has had a permanent pacemaker implanted. Recently, the patient has been feeling faint and on one occasion lost consciousness. What tests need to be undertaken to ascertain whether these symptoms are related to the patient’s pacemaker?

Ongoing pacemaker reviews

After discharge, the patient should attend a face-to-face pacemaker review within two to 12 weeks (BHRS 2020). Following that first post-discharge review, regular and ongoing follow-up reviews are required, the frequency of which will be set by the cardiac physiologist. According to the BHRS (2020) guidelines, the frequency of follow-up reviews may range from between three months and one year.

At each pacemaker review, a cardiac physiologist will investigate the patient’s clinical symptoms to check for newly developing conditions and for any deterioration in existing conditions, such as atrial fibrillation, ventricular arrhythmias and heart failure (BHRS 2020). Pacemaker reviews provide an opportunity to check the patient for pacemaker syndrome (Glikson et al 2021), inspect the wound and discuss any concerns the patient may have. Each pacemaker review will include a technical inspection of the device, notably to check battery life, lead integrity, capture threshold and device sensitivity. Diagnostic data and information regarding battery status and lead function are stored within the pacemaker (Eftekhari 2017) and can be accessed at the face-to-face review or potentially downloaded via the patient’s home monitor.

Ventricular pacing can cause dyssynchronous physiological ventricular contraction, which in turn can lead to progressive left ventricular dysfunction and symptoms of heart failure (Glikson et al 2021), so it is good practice, where possible, to reduce the rate of ventricular pacing. Reducing right ventricular pacing is sometimes achieved by adjusting programming settings – for example, decreasing the base rate or increasing atrioventricular delay to increase the opportunity for intrinsic ventricular activity to occur – and/or by reviewing the patient’s medicines – for example reducing the dosage of beta-blockers.

More frequent pacemaker reviews may be required if there are any issues that warrant closer monitoring, notably if the patient develops symptoms such as palpitations, breathlessness, fatigue, syncope, pre-syncope and/or chest pain. A simple pacemaker check will show whether the symptoms may be due to arrhythmia, lead fracture, a programming issue or a pacing lead or pacemaker box malfunction.

Traditionally, follow-up reviews have been undertaken face to face, but technological advances now enable cardiac implantable electronic devices to self-monitor and communicate remotely. Technologies such as wireless remote monitoring are likely to be increasingly used for the follow-up of patients with cardiac implantable electronic devices, including pacemakers (BHRS 2020). Any clinical information downloaded remotely would still require review by a cardiac physiologist; in addition, less frequent face-to-face reviews would still be required to monitor symptoms and undertake manual threshold checks and programming changes.

Conclusion

Temporary and permanent pacemakers are commonly used to treat significant bradyarrhythmia. Cardiac pacing is an invasive intervention that carries significant risk, particularly relating to lead and device insertion, implantation and removal. It is important that nurses understand the principles of cardiac pacing, the indications for the use of temporary and permanent pacemakers, and the support and information needs of patients, so that they can support patients at every stage, provide close monitoring and promptly treat or escalate any complications.

TIME OUT 6

Consider how understanding cardiac pacing principles and interventions relates to The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates (Nursing and Midwifery Council 2018) or, for non-UK readers, the requirements of your regulatory body

TIME OUT 7

Now that you have completed the article, reflect on your practice in this area and consider writing a reflective account: rcni.com/reflective-account

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