Pacemakers and their problemsSept 2013

Indications

•Symptomatic heart block•Symptomatic sinus brady•AF with symptomatic brady

Also:•Cardiac Resynchronization Therapy•Defibs

Device =

Mode =

Normal: atria and ventricle paced

Normal: ventricle paced

Who

Car

es?

http://jhcedecg.blogspot.ie/2013/09/ecg-of-week-16th-september-2013_18.html

http://lifeinthefastlane.com/ecg-library/pacemaker/

https://gmep.org/media

http://jhcedecg.blogspot.ie/2013/09/ecg-of-week-16th-september-2013_18.html

Problems

Early:•Infection•Bleeding•Lead misplacement•Pacemaker syndrome (poor coordination)•thrombosis

Late:•Battery•failure•runaway pacemaker

•Lead Fracture•Skin Erosion•‘Twiddler’s syndrome’•thrombosis (usually chronic and not a problem)

General:•Mis-sensing•Pacemaker mediated tachy

Pacemaker mediated tachy [=AVRT]http://lifeinthefastlane.com/ecg-library/pacemaker-malfunction/

Runaway pacemaker

Magnet Mode

Lead Fracture

Falls & BlackoutsApril 2012

Falls and blackouts

Acknowledgements/images•Life in the fast lane•Sonocloud.org•Andy Buck•the wonders of YouTube and Wiki•Amal Mattu

Falls and Blackouts

Blackout/Syncope

Falls

http://www.youtube.com/watch?v=DU_i0ZzIV5U

Blackouts/Syncope

Serious Benign•Cardiac•HOCM•Brugada•ARVH•QT•AS•Arrhythmias...•PE•Aortic•Ectopic•SAH•Seizure•?TIA

•Neurocardiogenic/vasovagal/faint•Meds•Micturition/Cough syncope•Necktie/Shaving syncope

Cardiac

•sudden•palpitations•chest pain•witnessed•? LOC

•? murmur•vital signs (RR!)•cognition•neuro

ECG? Blood Sugar

History Exam

HOCM

HOCM

Brugada

•Likely common cause of SCD•ICD only treatment•presence of symptoms is important•Quoted 10% mortality a year if untreated (though recent evidence questions this...)

PMID 20100972

RBBB Brugada Brugada

Orthodromic Antidromic

Normal AF WPW AF

Long QT

•Just use the calculated QTc•>500ms before badness happens

Causes

•Syndrome - rare•Low electrolytes•All the drugs in the world...

CH

ES

S

San Fran/CHESS

The rule performed with a sensitivity of 90% (44/49 outcomes; 95% confidence interval [CI] 79% to 96%) and a specificity of 33% (95% CI 32% to 34%).

Rule performance to predict serious outcomes was sensitivity 74% (95% CI 61% to 84%), specificity 57% (95% CI 53% to 61%)

The rule was 98% sensitive (95% confidence interval [CI] 89% to 100%) and 56% specific (95% CI 52% to 60%) to predict these events.

Falls in the elderly

Serious Benign

•Everything... •Nothing...

ACS

•Common•Usually with an associated “anginal equivalent” (lethargy, diaphoresis, shortness of breath) •If isolated blackout with no symptoms prior or after then unlikely (quoted <1% pick up rate for trops in syncope)•Difficulty given baseline ECG changes and renal function

Found on the floor...

•Rhabdo•Hypothermia•Fractures

If they’re now back to baseline?

PMID: 17200478

Risk Assessment

Timed up and go [>20 secs abnormal]

http://www.youtube.com/watch?v=dsTfqk9ZTiw

As yet...

There is no good, reliable test

•Risk assessment•Gait assessment•Have they fallen in the past year

•Falls clinic/assessment

Driving regulations?

Provoked: