Risk of Pacemaker Failure

A recent case has prompted this item to remind registrants of the need for vigilance regarding the risk of pacemaker failure that can occur even with regular pacemaker clinic follow-up. Current pacemaker hardware is highly reliable. Despite this, pacemaker failure can occur due to many reasons and should be considered when patients with pacemakers present with a low heart rate.    

The patient had a history of hypertension with congestive heart failure, atrial fibrillation, as well as complete heart block requiring a pacemaker. The patient had been experiencing frequent episodes of dizziness, weakness, and low heart rate. The patient underwent an electrocardiogram which demonstrated significant bradycardia with a heart rate in the 30s. The patient was assessed and their beta-blocker dose was reduced but subsequently died as a result of pacemaker failure. Examination at the outpatient visit did not reflect consideration of pacemaker failure despite a heart rate of 30 or identify the need for emergency intervention to address this.   

A reminder for all registrants: 

• Symptomatic bradycardia is a medical emergency and all patients who present to an outpatient clinic with symptomatic low heart rate should be directed to the emergency department.
• When assessing patients who have a pacemaker who have a heart rate lower than the set pacemaker rate or abnormal electrocardiogram, consider the possibility of pacemaker failure, even in the context of regular pacemaker clinic follow-up.
• Electrocardiogram readings do not provide advice and cannot be relied upon to direct our medical treatment.
• Consider broad system causes in your differential diagnosis and document this in your medical records.
• Seek emergency medical consultation in the event of extreme bradycardia, even if close medical follow-up with specialty care such as cardiology has been arranged.