ABSTRACT
The aging population in USA is growing exponentially, and the number of cardiac implantable electrical devices (CIEDs) is expected to grow proportionally. The most common presentations of bradyarrhythmias are: sinus node dysfunction (SND), atrioventricular block (AVB), and carotid sinus hypersensitivity (CSH). These conditions frequently affect older patients, and pacemaker implantation is the therapy of choice. Few clinical trials have focused exclusively on the elderly; however, the age in most clinical trials of CIEDs ranges between 70 and 75 years. The best pacing mode for each one of the conditions listed above has been a source of debate. Atrial or dual chamber pacing is preferred for SND. Exclusive ventricular pacing is associated with higher risk of atrial fibrillation and possible increased rate of stroke. For patients with AVB, most trials have not shown any significant difference in outcomes between single or dual chamber pacemaker, and the choice should be based on the patient’s lifestyle and physical activities. Limited data about pacing in CSH is available; dual chamber pacemaker is the preferred choice for these patients. Current data suggests that very elderly pacemaker recipients have similar outcomes compared to the age-matched general population. Thus, advanced age should not preclude the recommendation of pacing. Health care providers should be aware of end of life issues in pacing therapy. Proactive communication is crucial with very elderly patients or their legal guardians on topics related to withholding or withdrawing such therapy at the end of life.
