Pacemaker implantation in the elderly: can the patient's level of dependence select the best candidates for device implantation?
Authors: Quintal J , Flores R , Goncalves S , Ferreira J S , Coelho R A , Pohle C L , Duarte T , Seixo F 
Published: June 2024

Abstract

Background
Growing life expectancy amplifies cardiovascular disease prevalence, fueling a surge in implantable device use. Ethical and legal questions about the appropriate use, maintenance, and deactivation of such devices in the elderly have been raised but there is scarse data on which patients (pts) would benefit from pacemaker implantation (PMi).

Aim
To assess the potential of patient dependency level in activities of daily living (ADLs) as a criteria for elderly patient selection for PMi based on clinical outcomes after PMi.

Methods
We performed a single-center retrospective cohort study. Consecutive pts aged 80 years-old (y) who underwent PMi in our center between 1 November 2021 and 1 November 2023 were enrolled (n=211). PM generator changes were excluded (n=65). Two groups were formed according to pts dependency level for ADLs in Barthel score: active pts (gA) and partial/total dependent pts (gB). Baseline characteristics, PMi indication, urgency level, symptoms upon admission, time-lag until PMi, mean in-hospital stay duration, procedural and infectious complications and all-cause mortality were assessed and compared between the groups.

Results
The study included 146 pts, with a mean age of 86 (± 4) y and 53% male prevalence.
GA included 111 pts, while gB included 35 (24%) pts. No significant differences between the groups regarding cardiovascular risk factors were seen - table 1. Dependent pts were more often submitted to urgent PMi (88.6 vs 58.6%, p=0.001). Complete atrioventricular block (AVB) was the main indication for PMi (43.8%), followed by Brady-AFib/Flutter (17.8%), Sinus Node Dysfunction (14.4%), Symptomatic 2nd degree AVB (12.3%) and Tachy-Brady Syndrome (6.2%). AVB was more frequent in gB (62.9 vs 37.8%, p=0.009). Regarding symptoms, syncope was the main complaint in gA (31.5%, p=0.046) and altered state of consciousness the most frequent one in gB (17.1%; p=0.038).
Median in-hospital stay duration was 4 (1-79) days with a median time-lag until PMi of 4 days. The length of in-hospital stay was significantly longer in gB – median 5(1-79) vs 4(1-45) days, p=0.023. Remarkably, infections during hospitalization were far more common in dependent pts (45.7 vs 24.3%, p=0.015), mainly due to nosocomial infections (37.1% gB vs 18.9% gA, p=0.026). During a median follow-up time of 10 (0-25) months, 22 deaths were verified. Mortality was higher in gB (31.4% vs 9.9%; p=0.002), with a median time until death of 2 (0-9) months and a probability of survival of 68.9% – figure 1.

Conclusions
Our study suggests that PM implantation in pts over 80y with dependence leads to longer hospitalizations with infections and provides no additional mortality benefit compared to active pts. Therefore, criteria selection of elderly who would benefit from PMi should take into account not only patient’s frailty and comorbidities but also a patient/family engaged decision according to his autonomy.