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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.

Permanent pacemakers

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical 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.
  • 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.

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.

Over-sensing

Noise, myopotentials or T waves are mistaken for cardiac activity, inhibiting pacing and potentially causing dangerous pauses in a dependent patient.

Pocket or system infection

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.

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.

  1. Document symptom-rhythm correlation and exclude reversible medicines, metabolic causes, acute ischaemia and sleep-related physiology where relevant.
  2. Assess baseline rhythm, AV conduction, chronotropic response, ventricular function and anticipated pacing burden.
  3. Choose 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.
  4. Use shared decision-making covering benefits, infection/lead risks, generator changes, follow-up and driving implications.
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Sources and review status6 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE TA324: Dual-chamber pacemakers for symptomatic SNDDevice recommendation for symptomatic SND without AV block.
  • ESC: 2021 cardiac pacing and CRT guidelineIndications, mode selection and follow-up.
  • NHS: Pacemaker implantationProcedure, recovery, review schedule and urgent symptoms.
  • Resuscitation Council UK: Adult advanced life support 2025Acute bradycardia and pacing bridge.
  • Resuscitation Council UK: Adult bradyarrhythmia algorithm 2025Current adverse-bradycardia and temporary-pacing sequence.
  • DVLA: Cardiovascular disorders and fitness to driveCurrent Group 1 and Group 2 restrictions and notification requirements after pacemaker implantation.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom