Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Escalate
A pacemaker patient with syncope, severe bradycardia, shock, chest pain or acute breathlessness needs monitored emergency assessment. Treat the clinical bradyarrhythmia, use transcutaneous pacing if needed and arrange urgent device interrogation; a pacing spike alone does not prove capture.
Synopsis
Understand pacing indications and modes, recognise device malfunction or infection, and provide safe post-implant and long-term follow-up.
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.
Key red flags
Failure to capture
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.
Investigation priorities
01
12-lead ECG with rhythm stripFirst step
Assess intrinsic rhythm, paced morphology, capture and sensing.
Management branches
selectionAssessing for permanent pacing
Symptomatic bradycardia, pauses or conduction disease persists.
Document symptom-rhythm correlation and exclude reversible medicines, metabolic causes, acute ischaemia and sleep-related physiology where relevant.
Assess baseline rhythm, AV conduction, chronotropic response, ventricular function and anticipated pacing burden.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.