01Purpose and principlesWhat the treatment does and how it fits into care.
A pacemaker senses intrinsic cardiac activity and delivers a timed electrical impulse when the programmed condition is met. The device, lead configuration and programming should reproduce useful physiology while avoiding unnecessary pacing and symptoms.
The indication and rhythm determine the system. Dual-chamber pacing can maintain AV synchrony in SND or AV block, whereas permanent AF with bradycardia often needs ventricular support; leadless systems are selected for particular anatomies and pacing requirements.
Follow-up is a clinical and technical process. Symptoms, wound and heart-failure status are reviewed alongside sensing amplitude, capture threshold, lead impedance, battery status, pacing percentages and stored arrhythmias.
Key points
- Permanent pacing is primarily for symptomatic irreversible bradycardia or clinically important conduction disease, not for an arbitrary low pulse in isolation.
- A single-chamber atrial system paces the atrium, a ventricular system paces the ventricle, and a dual-chamber system can preserve AV sequence.
- NICE recommends dual-chamber pacemakers as an option for symptomatic bradycardia due to sick sinus syndrome without AV block.
- Rate-responsive programming increases pacing rate with activity and can treat chronotropic incompetence.
- A pacing spike followed by the intended depolarisation is capture; a pulse or arterial waveform confirms mechanical response.
- Failure to capture, under-sensing and over-sensing have different ECG patterns and require interrogation, not blind reprogramming.
- Early complications include pneumothorax, haematoma, lead displacement, perforation and infection; late issues include lead failure, battery depletion and pacing-induced dysfunction.
02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.
A pacing spike is not followed by the expected P wave or QRS; causes include lead displacement, fracture, battery/generator problems, electrolyte disturbance or a raised myocardial threshold.
Inappropriate pacing spikes occur despite intrinsic beats because the device does not detect them; lead or programming problems are possible.
Noise, myopotentials or T waves are mistaken for cardiac activity, inhibiting pacing and potentially causing dangerous pauses in a dependent patient.
Loss of AV synchrony can cause fatigue, dyspnoea, hypotension, neck pulsation or presyncope despite an apparently adequate rate.
Erythema, swelling, pain, discharge, erosion, fever or unexplained bacteraemia may represent device infection and requires urgent specialist review; do not treat a draining pocket with oral antibiotics alone.
Right-ventricular pacing usually produces a broad left-bundle-like QRS; atrial pacing produces a spike before the P wave. Compare with the programmed mode and prior tracings.
03Assessment before treatmentTests and checks that guide safe selection.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
12-lead ECG with rhythm stripFirst step - Why
- Assess intrinsic rhythm, paced morphology, capture and sensing.
- Interpretation and limitations
- Relate every spike to atrial or ventricular depolarisation and check for inappropriate inhibition or pacing.
- 02
Device interrogation - Why
- Read battery, lead measurements, pacing burden, episode logs and programmed settings.
- Interpretation and limitations
- A change in impedance or threshold can indicate lead damage or displacement; stored electrograms help adjudicate arrhythmias.
- 03
Chest radiograph - Why
- Check lead position and pneumothorax after implantation or suspected displacement/fracture.
- Interpretation and limitations
- Compare with the post-implant baseline; a normal radiograph does not exclude an electrical lead problem.
- 04
Echocardiogram - Why
- Assess pericardial effusion/perforation concern, valve interaction and ventricular function.
- Interpretation and limitations
- New effusion with chest pain or hypotension is urgent; falling LVEF with high RV pacing may suggest pacing-induced cardiomyopathy.
- 05
FBC, CRP and blood cultures - Why
- Investigate fever, pocket inflammation or unexplained bacteraemia.
- Interpretation and limitations
- Take cultures before antibiotics when the patient is stable enough; device infection often requires complete system extraction.
- 06
U&Es and magnesium - Why
- Find electrolyte abnormalities that raise capture thresholds or provoke arrhythmia.
- Interpretation and limitations
- Correct material abnormalities while device function is secured.
04Treatment approachPreparation, options, escalation and aftercare.
01selectionAssessing for permanent pacingFirst stepSymptomatic bradycardia, pauses or conduction disease persists.+
- 1Document symptom-rhythm correlation and exclude reversible medicines, metabolic causes, acute ischaemia and sleep-related physiology where relevant.
- 2Assess baseline rhythm, AV conduction, chronotropic response, ventricular function and anticipated pacing burden.
- 3Choose single-, dual-chamber, leadless or resynchronisation-capable pacing according to rhythm and cardiac structure; dual-chamber pacing is a NICE option for symptomatic SND without AV block.
- 4Use shared decision-making covering benefits, infection/lead risks, generator changes, follow-up and driving implications.
02implantImplantation and dischargeA permanent device has been selected.+
- 1Use sterile implantation with appropriate peri-procedural monitoring and confirm lead position, sensing and capture.
- 2Before discharge, interrogate the device, inspect the wound and provide the device identification card and emergency contact details.
- 3Advise wound care and gradual arm movement; avoid heavy lifting or vigorous exercise with the implant-side arm for 4-6 weeks as advised by the implanting team.
- 4Explain driving restrictions and the duty to notify DVLA/insurer; Group 1 driving is generally withheld for at least 1 week after uncomplicated pacemaker implantation, subject to current DVLA rules and the underlying condition.
03malfunctionSuspected pacemaker malfunctionSyncope, bradycardia, abnormal spikes or a device alert occurs.+
- 1Assess ABCDE, monitor continuously, obtain a 12-lead ECG and determine whether the patient is pacemaker-dependent.
- 2If unstable bradycardia persists, use the RCUK bradyarrhythmia pathway and transcutaneous pacing while seeking urgent device expertise.
- 3Interrogate the device and check electrolytes, lead position and recent procedures or electromagnetic exposure.
- 4Correct the cause and arrange lead revision, generator change or reprogramming through the device team; never rely on a normal pulse after a transient event.
04infectionSuspected device infectionPocket inflammation/erosion, fever or bacteraemia is present.+
- 1Admit or seek urgent device/infectious-disease assessment according to clinical stability; obtain blood cultures before antibiotics when safe.
- 2Use echocardiography, often TOE, when lead or valve endocarditis is suspected.
- 3Start pathogen-directed IV antibiotics after cultures, with empirical therapy only when clinically necessary and adjusted promptly to results.
- 4DefinitiveArrange complete system extraction when device infection is confirmed; pocket-only oral antibiotics without extraction are not definitive treatment.
05Complications, monitoring and follow-upAdverse effects, response and longer-term review.
- Inspect the wound and review symptoms at early follow-up, commonly around 6 weeks.
- Interrogate sensing, capture threshold, lead impedance, battery longevity and pacing percentages at each device review.
- Review stored atrial high-rate episodes and ventricular arrhythmias clinically rather than treating device labels alone.
- Assess ventricular function when RV pacing burden is high or heart-failure symptoms develop.
- NHS patient guidance describes cardiology review at 3-6 months and pacemaker-clinic review at least annually thereafter, with more frequent checks near battery depletion.
- Monitor for redness, swelling, discharge, fever, erosion, recurrent presyncope or diaphragmatic stimulation between scheduled visits.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Capture is electrical and mechanical
A QRS after a spike is only electrical capture. In an unstable patient, confirm a pulse, blood-pressure waveform or other mechanical output.
Magnet effects differ
A magnet commonly makes a pacemaker pace asynchronously, but response varies by manufacturer and programming. Use only with device expertise and monitoring.
Mode follows rhythm
An atrial lead offers no useful tracking in permanent AF, while ventricular-only pacing can create AV dyssynchrony in sinus rhythm.
High RV pacing can matter
Dyssynchronous RV apical pacing can worsen ventricular function in some patients; anticipated burden and LVEF influence system selection or upgrade.
Infection is a system disease
Pocket erosion exposes hardware and is treated as infection even without fever; definitive care usually includes complete hardware removal.
Remote monitoring complements clinic
Alerts can detect lead or battery changes early, but they do not replace wound assessment, symptom review and scheduled in-person evaluation.
07Common pitfallsFrequent interpretation and management errors.
- 01
Assuming a visible pacing spike means the heart has been captured.
- 02
Calling any broad QRS in a paced patient ventricular tachycardia without checking spike timing and prior paced morphology.
- 03
Treating pocket erosion with oral antibiotics alone.
- 04
Applying a magnet without knowing whether the device is a pacemaker or ICD and what response is programmed.
- 05
Ignoring new heart failure in a patient with a high ventricular pacing percentage.