Pacemakers: Pacemakers: The Recommendations and The Recommendations and Guidelines for our patient Guidelines for our patient

population today.population today.

By: Michelle Miller OMSIIIBy: Michelle Miller OMSIII

Millcreek HospitalMillcreek Hospital

May 31, 2006May 31, 2006

Objectives and Learning Objectives and Learning TopicsTopics

• Recommendations for Pacemaker Recommendations for Pacemaker TherapyTherapy

• Types of PacemakersTypes of Pacemakers

• The most appropriate Pacemakers The most appropriate Pacemakers for each conditionfor each condition

• Contraindications and WarningsContraindications and Warnings

Pace yourself for the Facts on Pace yourself for the Facts on Pacemakers.Pacemakers.

• First Pacemaker was implanted in 1958 First Pacemaker was implanted in 1958 • In the USA 300,000 people have In the USA 300,000 people have

pacemaker implants per year.pacemaker implants per year.• Worldwide 900,000 people have Worldwide 900,000 people have

pacemaker implants per year.pacemaker implants per year.• First Pacers were Fixed Rate Pacers today First Pacers were Fixed Rate Pacers today

we use Rate Responsive Pacemakers.we use Rate Responsive Pacemakers.• Most Conditions Requiring Pacers are Most Conditions Requiring Pacers are

Bradyarrythmias/Tachyarrythmias.Bradyarrythmias/Tachyarrythmias.

Class Recommendations from Class Recommendations from the ACC/AHA for Pacemaker the ACC/AHA for Pacemaker

TherapyTherapy• Class I:Class I: Conditions for which there is Conditions for which there is

evidence and/or general agreement that evidence and/or general agreement that a given procedure or treatment is a given procedure or treatment is beneficial, useful, and effective.beneficial, useful, and effective.

• Class II:Class II: Conditions for which there is Conditions for which there is conflicting evidence and/or a divergence conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of opinion about the usefulness/efficacy of of a procedure or treatment.of of a procedure or treatment.

Class Recommendations Class Recommendations ContinuedContinued

• Class IIaClass IIa: Weight of evidence/opinion is in : Weight of evidence/opinion is in favor of usefulness/efficacyfavor of usefulness/efficacy

• Class IIbClass IIb: Usefulness/ efficacy is less well : Usefulness/ efficacy is less well established by evidence/opinionestablished by evidence/opinion

• Class IIIClass III: Conditions for which there is : Conditions for which there is evidence and/or general agreement that a evidence and/or general agreement that a procedure /treatment is not useful/ procedure /treatment is not useful/ effective and in some cases may be effective and in some cases may be harmful.harmful.

Levels of Evidence that support Levels of Evidence that support recommendations of recommendations of Pacemaker TherapyPacemaker Therapy

– Level A:Level A: Data derived from multiple Data derived from multiple randomized clinical trials involving a large randomized clinical trials involving a large number of individualsnumber of individuals

– Level B:Level B: Data derived from a limited number Data derived from a limited number of trials involving comparatively small numbers of trials involving comparatively small numbers of patients or from well-designed data analysis of patients or from well-designed data analysis of nonrandomized studies or observational of nonrandomized studies or observational data registriesdata registries

– Level C:Level C: Consensus of expert opinion was the Consensus of expert opinion was the primary source of recommendationprimary source of recommendation

Overview of “A BAD BEAT Overview of “A BAD BEAT STORY”STORY”• AV blockAV block• Bifascicular and trifascicular blockBifascicular and trifascicular block• AV block associated with myocardial infarctionAV block associated with myocardial infarction• Sinus node dysfunctionSinus node dysfunction• Hypersensitive Carotid Sinus Syndrome (CSS)Hypersensitive Carotid Sinus Syndrome (CSS)• Vasovagal Syncope (VVS)Vasovagal Syncope (VVS)• Tachyarrhythmias/Prevention of TachycardiasTachyarrhythmias/Prevention of Tachycardias• Hypertrophic CardiomyopathyHypertrophic Cardiomyopathy• Pacing after cardiac transplantationPacing after cardiac transplantation• Children and adolescents with Congenital Heart Children and adolescents with Congenital Heart

Conditions.Conditions.

Symptomatic Indications for Symptomatic Indications for Pacer TherapyPacer Therapy

• Syncope or pre-syncopeSyncope or pre-syncope

• DizzinessDizziness

• Congestive heart failureCongestive heart failure

• Mental confusionMental confusion

• PalpitationsPalpitations

• Shortness of breathShortness of breath

• Exercise intoleranceExercise intolerance

Recommendations for Recommendations for Pacemaker Therapy In AV Pacemaker Therapy In AV

BlockBlock• Class I:Class I:

1.)Third Degree Block and Type II second-degree 1.)Third Degree Block and Type II second-degree AV block at any anatomic level, associated AV block at any anatomic level, associated with any one of the following conditions:with any one of the following conditions:

-Bradycardia with symptoms (C)-Bradycardia with symptoms (C)

-Arrhythmias and other medical conditions that -Arrhythmias and other medical conditions that require drugs that result in symptomatic require drugs that result in symptomatic bradycardia. (C)bradycardia. (C)

-documented periods of asystole greater than or -documented periods of asystole greater than or equal to 3.0 seconds or any escape rate less equal to 3.0 seconds or any escape rate less than 40 BPM in awake or symptom free pts. than 40 BPM in awake or symptom free pts. (B,C)(B,C)

Continued AV Block Pacemaker Continued AV Block Pacemaker Recommendations Recommendations

Class I:Class I: Third Degree Block and Type II second- Third Degree Block and Type II second-degree AV block at any anatomic level, degree AV block at any anatomic level, associated with any one of the following associated with any one of the following conditions:conditions:

-After catheter ablation of the AV junction. (B,C)-After catheter ablation of the AV junction. (B,C)-Postoperative AV block that isn’t expected to -Postoperative AV block that isn’t expected to

resolve. (C)resolve. (C)-neuromuscular diseases with AV block, such as -neuromuscular diseases with AV block, such as

myotonic muscular dystrophy, Kearns-Sayre myotonic muscular dystrophy, Kearns-Sayre syndrome, Erb’s dystrophy, with or without syndrome, Erb’s dystrophy, with or without symptoms, because there may be symptoms, because there may be unpredictable progression of AV conduction unpredictable progression of AV conduction diseases. (B)diseases. (B)

AV Block Pacemaker AV Block Pacemaker RecommendationsRecommendations

• Class I :Class I : 2.)Second Degree AV Block regardless of type or site 2.)Second Degree AV Block regardless of type or site

in the presence of symptomatic bradycardia. (B)in the presence of symptomatic bradycardia. (B)• Class IIa: Class IIa: • 1.Asymptomatic third degree AV block. (B,C)1.Asymptomatic third degree AV block. (B,C)• 2.Asymptomatic type II second-degree AV block 2.Asymptomatic type II second-degree AV block

occurs with a narrow QRS. (B)occurs with a narrow QRS. (B)• 3.Asymptomatic type I second-degree AV block at 3.Asymptomatic type I second-degree AV block at

intra- or infra- His levels found at intra- or infra- His levels found at electrophysiologic study performed for other electrophysiologic study performed for other indications. (B)indications. (B)

• 4.First or second degree AV block with symptoms 4.First or second degree AV block with symptoms of pacemaker syndrome. (B)of pacemaker syndrome. (B)

Recommendations for Recommendations for Pacemaker Therapy with Pacemaker Therapy with

Bifascicular and trifascicular Bifascicular and trifascicular block.block.• Class I:Class I:

1. Intermittent Third Degree AV Block. (B)1. Intermittent Third Degree AV Block. (B)2. Type II Second Degree AV Block (B)2. Type II Second Degree AV Block (B)3.Alternating Bundle Branch Block (C)3.Alternating Bundle Branch Block (C)Class IIA:Class IIA: 1.Syncope not to be due to AV block when other likely 1.Syncope not to be due to AV block when other likely

causes have been excluded. (B)causes have been excluded. (B)2.Incidental findings at electrophysiologic study of 2.Incidental findings at electrophysiologic study of

markedly prolonged HV interval (greater than or markedly prolonged HV interval (greater than or equal to 100 milliseconds.) (B)equal to 100 milliseconds.) (B)

3. Incidental finding at electrophysiological study of 3. Incidental finding at electrophysiological study of pacing induced infra-His block that is not pacing induced infra-His block that is not physiologic (B)physiologic (B)

Recommendations for Recommendations for Permanent Pacing S/P Acute MIPermanent Pacing S/P Acute MI• Class I:Class I:1.1. Persistent second-degree AV block in the Persistent second-degree AV block in the

His Purkinje system with bilateral bundle-His Purkinje system with bilateral bundle-branch block or third degree AV block branch block or third degree AV block within or below the His-Purkinje system s/p within or below the His-Purkinje system s/p MI. (B)MI. (B)

2.2. Transient advanced (second or third Transient advanced (second or third degree ) infranodal AV block and degree ) infranodal AV block and associated bundle branch block. (Use associated bundle branch block. (Use Electrophysiology for exact site.) (B)Electrophysiology for exact site.) (B)

3.3. Persistent and symptomatic 2Persistent and symptomatic 2ndnd and 3 and 3rdrd Degree AV Block. (C)Degree AV Block. (C)

Recommendations for Recommendations for Permanent Pacing in Sinus Permanent Pacing in Sinus

Node DysfunctionNode Dysfunction• Class I:Class I: 1.Sinus node dysfunction with documented 1.Sinus node dysfunction with documented

symptomatic bradycardia, including frequent symptomatic bradycardia, including frequent sinus pauses that produce symptoms. (C)sinus pauses that produce symptoms. (C)

2.Symptomatic chronotropic incompetence (C)2.Symptomatic chronotropic incompetence (C)Class IIA:Class IIA: 1. Sinus Node dysfunction occurring 1. Sinus Node dysfunction occurring

spontaneously or as a result of necessary drug spontaneously or as a result of necessary drug therapy with heart rate less then 40 BPM when a therapy with heart rate less then 40 BPM when a clear association between significant symptoms clear association between significant symptoms consistent with bradycardia and it hasn’t been consistent with bradycardia and it hasn’t been documented.(C)documented.(C)

2. Syncope of unexplained origin when major 2. Syncope of unexplained origin when major abnormalities of sinus node function are abnormalities of sinus node function are discovered or provoked in electrophysiologic discovered or provoked in electrophysiologic studies.(C)studies.(C)

Recommendations for Pacing Recommendations for Pacing that detect and pace to that detect and pace to terminate tachycardias.terminate tachycardias.

• Class I:Class I: NONE NONE

• Class IIa:Class IIa: Symptomatic recurrent SVT Symptomatic recurrent SVT that is reproducibly terminated by that is reproducibly terminated by pacing in the unlikely event that pacing in the unlikely event that catheter ablation and /or drugs fail to catheter ablation and /or drugs fail to control the arrhythmia or produce control the arrhythmia or produce intolerable side effects. (C)intolerable side effects. (C)

Pacing Recommendations to Pacing Recommendations to Prevent TachycardiaPrevent Tachycardia

• Class I:Class I: Sustained paused – Sustained paused – dependent VT, with or without dependent VT, with or without prolonged QT, in which the efficacy prolonged QT, in which the efficacy of pacing is thoroughly documented. of pacing is thoroughly documented. (C)(C)

• Class IIA:Class IIA: High risk patients with High risk patients with congenital long QT syndrome. (C)congenital long QT syndrome. (C)

Recommendations for Pacing Recommendations for Pacing Neurocardiogenic Syncope Neurocardiogenic Syncope

(ex.Hypersensitive Carotid Sinus; Vasovagal (ex.Hypersensitive Carotid Sinus; Vasovagal Syncope)Syncope)

• Class I:Class I: Recurrent syncope caused by carotid sinus Recurrent syncope caused by carotid sinus stimulation; minimal carotid sinus pressure induces stimulation; minimal carotid sinus pressure induces ventricular asystole of more than 3 seconds duration in the ventricular asystole of more than 3 seconds duration in the absence of any medication that depresses the sinus node or absence of any medication that depresses the sinus node or AV conduction. (C)AV conduction. (C)

• Class IIA:Class IIA: 1. Recurrent syncope without clear, provocative 1. Recurrent syncope without clear, provocative events and with a hypersensitive cardioinhibitory response. events and with a hypersensitive cardioinhibitory response. (C)(C)

• 2. Significantly symptomatic and recurrent neurocardiogenic 2. Significantly symptomatic and recurrent neurocardiogenic syncope associated with bradycardia documented syncope associated with bradycardia documented spontaneously or at the time of the tilt table testing. (B)spontaneously or at the time of the tilt table testing. (B)

Recommendations for Recommendations for hypertrophic cardiomyopathyhypertrophic cardiomyopathy

• Class IClass I: Use class I indications for : Use class I indications for sinus node dysfunction or AV block.sinus node dysfunction or AV block.(C)(C)

Recommedations s/p Cardiac Recommedations s/p Cardiac TransplantTransplant

• Class I:Class I: Symptomatic Symptomatic bradyarrhythmias/chronotropic bradyarrhythmias/chronotropic incompetence not expected to incompetence not expected to resolve and other Class I indications resolve and other Class I indications for permanent pacing.(C)for permanent pacing.(C)

Recommendations for pacing in Recommendations for pacing in Children, Adolescents and Patients Children, Adolescents and Patients

with Congenital heart diseasewith Congenital heart disease..• Class I: Class I: 1.1. Advanced 2Advanced 2ndnd or 3 or 3rdrd degree AV Block associated with degree AV Block associated with

bradycardia, ventricular dysfunction, or low cardiac bradycardia, ventricular dysfunction, or low cardiac output. (C)output. (C)

2.2. Sinus Node Dysfunction with correlation of Sinus Node Dysfunction with correlation of symptoms during age-inappropriate bradycardia. The symptoms during age-inappropriate bradycardia. The definition of bradycardia varies with the patient’s definition of bradycardia varies with the patient’s age and expected Heart Rate. (B)age and expected Heart Rate. (B)

3.3. Postoperative advanced 2Postoperative advanced 2ndnd and 3 and 3rdrd degree AV block degree AV block that isn’t expected to resolve or persists at least 7 that isn’t expected to resolve or persists at least 7 days after surgery. (B, C)days after surgery. (B, C)

4.4. Congenital 3Congenital 3rdrd degree AV Block in the infant with a degree AV Block in the infant with a ventricular rate <50 BPM or with congenital heart ventricular rate <50 BPM or with congenital heart disease and ventricular rate < 70 BPM. (B,C)disease and ventricular rate < 70 BPM. (B,C)

Recommendations for pacing in Recommendations for pacing in Children, Adolescents and Patients Children, Adolescents and Patients

with Congenital heart diseasewith Congenital heart disease continued….continued….

• 5. Congenital third degree AV Block 5. Congenital third degree AV Block with a wide QRS escape rhythm, with a wide QRS escape rhythm, complex ventricular ectopy or complex ventricular ectopy or ventricular dysfunction. (B)ventricular dysfunction. (B)

• 6. Sustained pause-dependent VT, 6. Sustained pause-dependent VT, with or without prolonged QT, in with or without prolonged QT, in which the efficacy of pacing is which the efficacy of pacing is thoroughly documented. (B)thoroughly documented. (B)

Recommendations for pacing in Recommendations for pacing in Children, Adolescents and Patients Children, Adolescents and Patients

with Congenital heart diseasewith Congenital heart disease continued….continued….• Class IIa:Class IIa: 1.Bradycardia-tachycardia syndrome with the need for long-1.Bradycardia-tachycardia syndrome with the need for long-

term antiarrhythmic treatment other than digitalis. (C)term antiarrhythmic treatment other than digitalis. (C)2.Congenital 32.Congenital 3rdrd Degree AV block beyond the first year of life Degree AV block beyond the first year of life

with an average heart rate less than 50 bpm, abrupt pauses with an average heart rate less than 50 bpm, abrupt pauses in ventricular rate that are two or three times the basic in ventricular rate that are two or three times the basic cycle lenghth, or associated with symptoms due to cycle lenghth, or associated with symptoms due to chronotropic incompetence. (B)chronotropic incompetence. (B)

3. Long-QT sydrome with 2:1 AV or 33. Long-QT sydrome with 2:1 AV or 3rdrd Degree AV Block. (B) Degree AV Block. (B)4. Asymptomatic sinus bradycardia in the child with complex 4. Asymptomatic sinus bradycardia in the child with complex

congenital heart disease with resting heart rate less than 40 congenital heart disease with resting heart rate less than 40 bpm or pauses in ventricular rate more than 3 seconds. (C)bpm or pauses in ventricular rate more than 3 seconds. (C)

5.Patients with Congenital Heart Disease and impaired 5.Patients with Congenital Heart Disease and impaired hemodynamics due to sinus bradycardia or loss of AV hemodynamics due to sinus bradycardia or loss of AV synchrony. (c)synchrony. (c)

Types of PacemakersTypes of Pacemakers

• Single Chamber Pacemaker:Single Chamber Pacemaker:1. Uses 1 lead in the right atria 1. Uses 1 lead in the right atria (VDD)(VDD) OR2. Uses 1 lead in the right ventricle 2. Uses 1 lead in the right ventricle (VVI)(VVI) • Dual Chamber Pacemaker (DDD):Dual Chamber Pacemaker (DDD):1. A lead in both the Right Atria and Right 1. A lead in both the Right Atria and Right

Ventricle.Ventricle.• Biventricular Pacemaker (DDDR) / (VAT):Biventricular Pacemaker (DDDR) / (VAT):1. Uses three leads: One in the right atrium, 1. Uses three leads: One in the right atrium,

one in the right ventricle and one in the one in the right ventricle and one in the left ventricle.left ventricle.

““Fantastic 4” Factors Fantastic 4” Factors influenced by the Pacemakerinfluenced by the Pacemaker

• Heart rate increaseHeart rate increase

• Stroke volume maximizationStroke volume maximization

• Atrial based pacingAtrial based pacing

• Normal ventricular activation Normal ventricular activation sequencesequence

Rate Responsive Pacing in the Rate Responsive Pacing in the presence of Respiratory presence of Respiratory

Function.Function.• Minute ventilation Minute ventilation

can be measured by can be measured by measuring the measuring the changes in changes in electrical electrical impedance across impedance across the chest cavity to the chest cavity to calculate changes calculate changes in lung volume over in lung volume over timetime

How a Rate Responsive Device How a Rate Responsive Device Works!Works!

Piezoelectric crystal

The Crystal Senses mechanical activity from the pacer and signals electrical activityback to the pacer to increase the rate of the pacer, there by increasing HR .

Circuitry

Battery

Pulse Generator

The Leads

Cathode Anode

Transvenous LeadsTransvenous LeadsPassive Fixation Lead tines are lodged

Into the Trabeculae

Active Fixation Leads are extendedinto the endocardium of the Heart,

this allows for them to positionanywhere in the heart.

Myocardial and Epicardial Myocardial and Epicardial leadsleads

Leads are applied directly to the heart.

They are fixed to the wall by:

1.Epicardial Stab in2.Myocardial Screw in 3.Suture on

Arrythmias that require Single Arrythmias that require Single Chamber Atrial PacingChamber Atrial Pacing

• Sinus Node Dysfunction with NML AV Sinus Node Dysfunction with NML AV and Intraventricular Conducting and Intraventricular Conducting System. System.

• Paroxysmal Atrial Fibrillation.Paroxysmal Atrial Fibrillation.

• ***Dual Chamber Pacing***Dual Chamber Pacing occurs for occurs for Sinus Node Dysfunction and PAF with Sinus Node Dysfunction and PAF with there is abnormal AV conduction seen there is abnormal AV conduction seen of EP studies.of EP studies.

Arrhythmias that require Dual Arrhythmias that require Dual Chamber PacingChamber Pacing

• 1. Sinus Sick Syndrome1. Sinus Sick Syndrome• 2.Chronic Second Degree Type II heart 2.Chronic Second Degree Type II heart

block.block.• 3. Chronic Third Degree Heart block3. Chronic Third Degree Heart block• 4. Recurrent Adams Stokes Syndrome. 4. Recurrent Adams Stokes Syndrome. • 5. Symptomatic Bilateral Bundle 5. Symptomatic Bilateral Bundle

Branch Block when tachyarrhythmias Branch Block when tachyarrhythmias and other Block causes are ruled out.and other Block causes are ruled out.

Arrhythmias that require Single Arrhythmias that require Single Chamber Ventricular PacingChamber Ventricular Pacing

1. Significant bradycardia and Nml Sinus 1. Significant bradycardia and Nml Sinus Rhythm with rare episodes of AV Block or Rhythm with rare episodes of AV Block or Sinus Arrest.Sinus Arrest.

Arrhythmias that require Arrhythmias that require Biventricular Pacing:Biventricular Pacing:

1.1. Chronic Atrial Fibrillation Treating Advanced Chronic Atrial Fibrillation Treating Advanced CHF in pts with major intraventricular CHF in pts with major intraventricular conduction defects predominantly LBBB.conduction defects predominantly LBBB.

Rate Responsive Device:Rate Responsive Device: 1.1. Chronotropic Incompetence. Chronotropic Incompetence.

Contraindications For…Contraindications For…

• 1. Dual Chamber Pacers and single chamber 1. Dual Chamber Pacers and single chamber pacers:pacers: Not indicated for Chronic Atrial Not indicated for Chronic Atrial Flutter/Fibrillation or Silent Atria, these particular Flutter/Fibrillation or Silent Atria, these particular pacers show no benefit in txt of the conditions.pacers show no benefit in txt of the conditions.

• 2. Single Chamber Ventricular Pacer:2. Single Chamber Ventricular Pacer: relatively relatively contraindicated in pt demonstrating “Pacemaker contraindicated in pt demonstrating “Pacemaker Syndrome”.Syndrome”.

• 3. Single Chamber Atrial Pacing:3. Single Chamber Atrial Pacing: relatively relatively Contraindicated in pt having AV conduction Contraindicated in pt having AV conduction compromise.compromise.

• 4.Rate Modulated Pacing:4.Rate Modulated Pacing: may be inappropriate for may be inappropriate for pt who experience angina or other symptoms of pt who experience angina or other symptoms of myocardial dysfunction at higher sensor driven myocardial dysfunction at higher sensor driven rates. rates.

Warnings For Pacemaker Warnings For Pacemaker Pts.Pts.

• To prevent damage to the To prevent damage to the electrode/tissue interface:electrode/tissue interface:

1.1. Avoid Sources of Magnetic and Avoid Sources of Magnetic and Electromagnetic Radiation.Electromagnetic Radiation.-MRI-MRI-Hydraulic Shock wave lithotripsy-Hydraulic Shock wave lithotripsy-No therapeutic ultrasounds within -No therapeutic ultrasounds within 6 inches of the pacemaker.6 inches of the pacemaker.

ReferencesReferences

• Gregoratos, Gabriel et al. ACC/AHA/NASPE 2002 Guideline Gregoratos, Gabriel et al. ACC/AHA/NASPE 2002 Guideline Updatefor Implantation of Cardiac Pacemakers and Updatefor Implantation of Cardiac Pacemakers and

Antiarrhythmia Devices.Antiarrhythmia Devices. http://www.acc.org.clinical/guidelines/pacemaker/I_indicatiohttp://www.acc.org.clinical/guidelines/pacemaker/I_indications.htm2002ns.htm2002..

• Pacemaker Implantation. Pacemaker Implantation. http://heartpoint.com/pacemakers.html#anchor510098http://heartpoint.com/pacemakers.html#anchor510098

• How do Pacemakers Work? British Heart Foundation. How do Pacemakers Work? British Heart Foundation. www.bhf.org.uk/hearthealth/index.asp?secID=1&secondlevwww.bhf.org.uk/hearthealth/index.asp?secID=1&secondlevel=79&thirdlevel=475&artID1632el=79&thirdlevel=475&artID1632

• Pacemakers. The Cleveland Clinic Heart and Vascular Pacemakers. The Cleveland Clinic Heart and Vascular Institute. Institute. http://www.clevelandclinic.org/heartcenter/pub/tests/procedhttp://www.clevelandclinic.org/heartcenter/pub/tests/procedures/pacemakers.htmures/pacemakers.htm

Review QuestionsReview Questions

1.1. A 65 yo white female presents in the ER s/p syncopal A 65 yo white female presents in the ER s/p syncopal episode. She states this has happened “a couple times” episode. She states this has happened “a couple times” before. Her EKG shows atrial fibrillation with LBBB. On before. Her EKG shows atrial fibrillation with LBBB. On physical exam she has no neurologic deficits, her heart is physical exam she has no neurologic deficits, her heart is irregularly, irregular and her lungs are CTA. Dr. D’Amico irregularly, irregular and her lungs are CTA. Dr. D’Amico is consulted and determines that this patient would is consulted and determines that this patient would benefit from a pacemaker. Being the astute benefit from a pacemaker. Being the astute resident/student that you are you determine the best resident/student that you are you determine the best pacer therapy for this particular patient’s condition would pacer therapy for this particular patient’s condition would be:be:

A.A. Fixed, Single Chamber Ventricular PacemakerFixed, Single Chamber Ventricular PacemakerB.B. Rate Modulated, Single Chamber Ventricular PacemakerRate Modulated, Single Chamber Ventricular PacemakerC.C. Fixed, Biventricular PacemakerFixed, Biventricular PacemakerD.D. Rate Modulated, Biventricular PacemakerRate Modulated, Biventricular PacemakerE.E. Rate Modulated, Dual Chamber PacemakerRate Modulated, Dual Chamber Pacemaker

Review QuestionsReview Questions

A 55 yo hispanic male presents with his chief A 55 yo hispanic male presents with his chief complaint of SOB and intermittent dizziness complaint of SOB and intermittent dizziness times 1 month. His O2 Sats at 100% on 2L times 1 month. His O2 Sats at 100% on 2L NC. On physical exam there are no NC. On physical exam there are no neurologic deficits, bradycardia, Lungs are neurologic deficits, bradycardia, Lungs are CTA. CT was negative, but his EKG had CTA. CT was negative, but his EKG had some interesting finding the PR interval some interesting finding the PR interval was fixed at .24 seconds and there is one was fixed at .24 seconds and there is one dropped QRS complex. With a ratio being 2 dropped QRS complex. With a ratio being 2 PR intervals to 1 QRS. PR intervals to 1 QRS.

This type of arrhythmia is:This type of arrhythmia is:

A.Second Degree Type one AV Block A.Second Degree Type one AV Block (Wenkebach)(Wenkebach)

B.Second Degree Type two AV BlockB.Second Degree Type two AV BlockC.Second Degree Type two Advanced AV BlockC.Second Degree Type two Advanced AV BlockD.Third Degree AV BlockD.Third Degree AV Block

Review QuestionsReview Questions

Using the previous questions Using the previous questions arrhythmia, does this pt. qualify for arrhythmia, does this pt. qualify for pacemaker therapy according to pacemaker therapy according to the recommendation guidelines by the recommendation guidelines by the ACC and AHA?the ACC and AHA?

A.A. YESYES

B.B. NONO