PERMANENT CARDIAC-PACEMAKERS IN THE ELDERLY

Objective: To review (1) Changes in cardiac impulse generation, conduc tion, and ventricular filling in normal aging and disease; (2) Pacemak er technology and nomenclature; (3) Expert guidelines about pacemaker use; (4) Studies of pacemaker effectiveness and utilization. Design: A rticles were identified through a Medline search, review of articles' bibliographies, and contact with pacemaker manufacturer representative s for information on device features and costs. These articles were re viewed, and the relevant data are presented. Results: Abnormalities in impulse generation and conduction are common in the elderly. Pacemake r use is higher in the elderly than in other population groups. Hemody namic changes associated with aging include an increased contribution of atrial contraction to ventricular filling. Pacemakers, which mainta in the synchrony between the atria and ventricles, may be particularly advantageous in the elderly for this reason. Rate-responsive ventricu lar pacemakers improve the quality of life compared with fixed rate de vices in some patients over the age of 75. Dual-chamber, sequential pa cemakers are more likely to reduce symptoms of pacemaker syndrome than ventricular pacemakers and probably also prolong survival and reduce risk of atrial fibrillation in certain groups of patients. However, du al chamber devices are more expensive and require more frequent follow -up. Pacemaker utilization can vary widely by region. Decisions about pacemakers require explicit tradeoffs between risk and quality of life on one hand and cost on the other. In many clinical situations, there is controversy as to whether pacemakers should be used. Conclusions: Pacemakers provide definite benefits to some patients, whereas in othe rs, the likelihood of benefit is uncertain. More sophisticated devices may provide some additional benefit, but they are more costly. Furthe r data is still required to define precisely which groups of patients substantially benefit from complex and expensive pacing modalities com pared with simpler ones.