Permanent cardiac pacemakers in the elderly.
OBJECTIVE
To review (1) Changes in cardiac impulse generation, conduction, and ventricular filling in normal aging and disease; (2) Pacemaker technology and nomenclature; (3) Expert guidelines about pacemaker use; (4) Studies of pacemaker effectiveness and utilization.


METHODS
Articles were identified through a Medline search, review of articles' bibliographies, and contact with pacemaker manufacturer representatives for information on device features and costs. These articles were reviewed, and the relevant data are presented.


RESULTS
Abnormalities in impulse generation and conduction are common in the elderly. Pacemaker use is higher in the elderly than in other population groups. Hemodynamic changes associated with aging include an increased contribution of atrial contraction to ventricular filling. Pacemakers, which maintain the synchrony between the atria and ventricles, may be particularly advantageous in the elderly for this reason. Rate-responsive ventricular pacemakers improve the quality of life compared with fixed rate devices in some patients over the age of 75. Dual-chamber, sequential pacemakers 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, dual 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 others, the likelihood of benefit is uncertain. More sophisticated devices may provide some additional benefit, but they are more costly. Further data is still required to define precisely which groups of patients substantially benefit from complex and expensive pacing modalities compared with simpler ones.
Bush
D E
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Department of Medicine, Johns Hopkins University School of Medicine, Francis Scott Key Medical Center, Baltimore, Maryland 21224.
Finucane
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D000367:Age Factors; D000368:Aged; D001145:Arrhythmias, Cardiac / Q000401:mortality / Q000628:therapy; D003362:Cost-Benefit Analysis; D006801:Humans; D010138:Pacemaker, Artificial / Q000191:economics