How a Pacemaker Treats an Irregular Heartbeat " Shirley a 75-year-old previously healthy woman"

Case study ( 9537 views as of April 22, 2024 )

Shirley is a 75-year-old previously healthy woman who visits her family doctor with a 2-month history of lightheadedness and weakness. She has no significant past medical history and is currently taking no prescription medications other than an occasional sleeping pill.

Her physical examination is essentially normal aside from a slow heart rate of 50 beats per minute. She is sent for an ECG which is interpreted as sinus bradycardia with a right bundle branch block and a first degree AV block. Her family doctor arranges for a holter monitor (heart rhythm monitor), which reveals occasional pauses up to 3.5 seconds in duration, which correlate with her symptoms of lightheadedness. On this basis she is referred for an urgent outpatient pacemaker implantation after discussion over the phone with a cardiologist.

Shirley and her family have a number of questions about what a pacemaker is, what it does, and how it will help her. Shirley is also concerned about the potential danger of the procedure itself as she was told that it would involve a type of surgery.

Shirley would benefit from some monitoring following her procedure, and should be assigned to a cardiologist for follow-up care. She can also speak with a pharmacist regarding her medications to identify any possible interactions.


Conversation based on: How a Pacemaker Treats an Irregular Heartbeat " Shirley a 75-year-old previously healthy woman"

How a Pacemaker Treats an Irregular Heartbeat " Shirley a 75-year-old previously healthy woman"

  • After a heart attack, making healthy lifestyle choices is crucial in addition to medical treatment. These lifestyle changes have both direct and indirect effects on the heart. A significant study showed that nine modifiable risk factors can predict around 90 percent of all heart attacks, and these factors can be positively influenced by adopting a healthier lifestyle. The modifiable risk factors that can be addressed through lifestyle changes include: Smoking: Quitting smoking is one of the most important steps in reducing the risk of heart attacks. High cholesterol: Following a heart-healthy diet low in saturated and trans fats, as well as maintaining a healthy weight, can help manage cholesterol levels. High blood pressure: Regular exercise, reducing sodium intake, adopting a healthy diet, limiting alcohol consumption, and managing stress are all effective in controlling blood pressure. Diabetes: Managing blood sugar levels through a balanced diet, regular exercise, and appropriate medication or insulin use is essential for individuals with diabetes. Fruit and vegetable intake: Consuming a diet rich in fruits and vegetables provides essential vitamins, minerals, and antioxidants that promote heart health. Truncal obesity: Maintaining a healthy weight, particularly around the waist, is beneficial for heart health. Regular exercise and a balanced diet can help achieve and maintain a healthy weight. Physical inactivity: Engaging in regular physical activity, such as aerobic exercises, can improve cardiovascular fitness and reduce the risk of heart attacks. High levels of psychosocial stress: Managing stress through relaxation techniques, counseling, and social support can help reduce the risk of heart problems. Moderate alcohol intake: If alcohol is consumed, it should be done in moderation, as excessive alcohol consumption can have detrimental effects on heart health. These lifestyle changes work synergistically with any prescribed medications from healthcare providers following a heart attack. Adopting a heart-healthy diet, engaging in regular exercise, and employing stress reduction techniques are crucial components of post-heart attack care and can significantly improve long-term outcomes and reduce the risk of future cardiovascular events. It is important to work closely with healthcare professionals to develop an individualized plan that addresses these lifestyle factors.
  • A stent is a medical device used to treat narrowed or blocked coronary arteries, which supply blood to the heart muscle. Symptoms of a narrowed artery include angina (chest pain), shortness of breath, and other discomforts. Some individuals may have silent ischemia, where they have a narrowing without noticeable symptoms, but it still increases the risk of complications. During a stent procedure, a wire mesh tube is inserted into the affected artery to keep it open, improving blood flow and relieving symptoms. Stents can be made of metal or be drug-eluting, releasing medication to prevent further narrowing. If you experience symptoms of angina or suspect a coronary artery narrowing, it is important to consult a healthcare professional. They can assess your condition, conduct necessary tests, and recommend suitable treatment options, which may include a stent procedure if appropriate.
  • Antiarrhythmic agents are medications used to control atrial fibrillation, a type of abnormal heart rhythm. These medications aim to maintain normal sinus rhythm and, if atrial fibrillation occurs, help the heart return to normal sinus rhythm. One commonly used antiarrhythmic agent is amiodarone, which has been on the market for a long time. However, it is associated with various side effects, including those related to the heart and other organ systems. Due to the potential risks and complexities associated with amiodarone, it is crucial that this medication is prescribed and monitored by a specialist with the assistance of a family doctor. Another antiarrhythmic agent is dronedarone, which is related to amiodarone. While it may be slightly less effective than amiodarone, it also has fewer side effects, which can be advantageous in certain cases. Sotalol, a beta-blocker medication, is another agent used to prevent recurrent episodes of atrial fibrillation. It also helps in controlling a rapid heart rate if atrial fibrillation occurs. Propafenone and flecainide are additional antiarrhythmic agents that are highly effective but typically reserved for patients with structurally normal hearts. It's important to have a discussion with your family physician or a specialist to understand the potential benefits and risks associated with these medications in your specific case. They can provide more detailed information and guide you in making informed decisions regarding the use of antiarrhythmic agents for atrial fibrillation management.
  • Atrial fibrillation significantly increases the risk of stroke, approximately five-fold compared to the general population. Strokes can have devastating consequences and lead to high rates of morbidity and other complications. For patients with atrial fibrillation, it is crucial to understand the importance of stroke prevention and adhere to their prescribed anticoagulant medication. Anticoagulants, often referred to as blood thinners, are taken daily to prevent the formation of blood clots (thrombus) that can travel to critical areas such as the brain and cause a stroke. It is vital for patients not to forget or miss their doses of blood thinners. One of the key aspects of stroke prevention in atrial fibrillation is medication compliance. Even missing a single dose can increase the risk of a stroke. It is important for patients to have a discussion with their prescribing physician to determine the most suitable anticoagulant for them, ensuring long-term compliance. Optimal compliance is essential for achieving the best outcomes. Currently, there are several stroke prevention medications available in the market. Warfarin is a well-known anticoagulant that has been used for over 40 years. However, it can be complicated for patients to take due to frequent blood tests and dosage adjustments, depending on factors such as other medications or dietary changes. Fortunately, there are newer anticoagulant drugs that are as safe as Warfarin and, in some cases, provide even better stroke reduction. These medications do not require frequent blood tests, and they come in once-a-day or twice-a-day versions, offering greater flexibility for patients and improving long-term compliance. When considering the right anticoagulant, patients should consider factors such as safety, side effects, and ease of use, and make an informed decision based on their specific needs. If you have atrial fibrillation and want to learn more about stroke prevention and the potential benefits of these newer anticoagulants, it is recommended to consult with your family doctor or a cardiologist to gather more information. Please note that the information provided is for informational purposes only and should not replace professional medical advice, diagnosis, or treatment. It is essential to consult with a healthcare professional for personalized guidance and care.
  • Cardioversion uses small, very safe electrical shocks to the heart to restore a normal rapid heartbeat.
  • There’s two main causes of sudden cardiac arrest. The first is when there’s a problem with the arteries, the plumbing in the heart. That’s coronary artery disease. The second one is when there’s a problem with the heart muscle. A technical term for that is cardiomyopathy.
  • A cardiac pacemaker is the natural pacemaker of your heart, which controls your heart rate. An artificial pacemaker is a small device that’s surgically placed under the skin of the chest and uses electrical pulses to help control your heartbeat. People with an arrythmia (irregular heartbeat) may require a pacemaker. An arrythmia can be caused by a heartbeat that's too fast (tachycardia) or too slow (bradycardia). An artificial cardiac pacemaker may be implanted temporarily after a heart attack or surgery. Or, you may require a permanent pacemaker to correct an irregular heartbeat. During the minor surgical procedure to implant your pacemaker, the physician will usually place it below the collarbone, and then connect it to the wires that lead to your heart. The device will monitor your heart rhythm and trigger an electrical impulse to correct your heartbeat when needed. Your artificial cardiac pacemaker will need to be replaced every 5 to 10 years. Many of today’s pacemakers can also monitor things like breathing and blood temperature, and can even adjust your heart rate to changes during activity.
  • Therefore, individuals with a pacemaker are dependent on that pacemaker to a varying degree, and its very important for us to know at all times whether or not the pacemaker is functioning perfectly well, and also we need to understand what the remaining battery life of the pacemaker is.
  • Anticoagulants are a class of medication commonly known as blood thinners. These drugs thin the blood. They usually do so in a predictable manner, and by doing that, we can prevent clots from forming in the heart. If we can prevent clots in the heart, we can prevent stroke due to atrial fibrillation.
  • Is an irregular heartbeat a condition that can be caused by bad diet ?
    • So the assumption could be made that Shirley had some kind of a genetic predisposition to arrhythmia that her bad diet exacerbated ?
    • It would be over generalizing to say that an unhealthy diet can lead to an irregular heartbeat in particular, but diet certainly does have an effect on overall heart health - there is well known evidence that omega-3 fatty acids are beneficial to heart health and cardiovascular disease reduction. Having said that, there have been links made between consumption of omega-3s and arrhythmia prevention so ensuring your diet includes these healthy fats wouldn't be a bad idea. Overall, I don't think an irregular heartbeat would be caused solely by diet, but diet could contribute to prevention.
  • That a great question, I would be interested in knowing that.
    • The way in which a pacemaker is inserted is that there is one or two leads that are inserted through a vein that tracks into the heart, and then the generator where the battery in the computer of the pacemaker is, that is then implanted underneath the skin.
    • A pacemaker is a very commonly used medical instrument that is implanted in someone in whom their natural pacemaker they were born with has for whatever reason failed. The heart is a muscle, and like any other muscle, needs a regular electrical impulse in order to do what it has to do, which is to pump.
  • Are there any dietary implications of using a pacemaker? I've read about dietary fish oil intake reducing heart rate - would this be applicable to a Pacemaker device at all?
    • Patients who have a pacemaker will likely be advised to follow a 'healthy heart diet' - and working with a registered dietitian can definitely help patients understand what this means. I know this would include looking at protein, omega-3 fatty acids and whole grain and vegetable intake. There would likely be recommendations given as well on restricting fatty and sugary foods.
  • What is a branch block and AV block ? Is this similar to a blocked valve ?
    • Both bundle branch and AV blocks restrict the electrical impulses that contribute to regular heartbeat. A branch block affects impulses going to left and right ventricles (bottom chambers of the heart), whereas an atrioventricular (AV) block affects impulse transmission from the atria to the ventricles (top chambers to bottom chambers). These differ from blocked valves, which occur when blood doesn't flow properly from one chamber into the next.
  • What lifestyle changes will she have to make once she has a pacemaker inserted?
    • I know that you have to avoid prolonged exposure to things with strong magnetic fields. You have to carry a pacemaker ID card and be aware of your pacemaker and your body so you can notify your doctor if something isn't working right.
  • When a person has a pacemaker is there certain situations they should avoid ? Would over exertion be something that could cause a problem with the pacemaker ?
    • That's very interesting. I would not have thought you would have to rest your arm after pacemaker surgery. Why is that ?
    • After a pacemaker is implanted, patients should rest their arm for a few weeks in order to avoid dislodgement of the leads (the wires that go to the heart). After the healing period, someone with a pacemaker should not be limited at all in their physical activities.
  • Even outpatient surgery - like this for her pacemaker - has an inherent amount of risk. I would urge her to have an indepth discussion with her cardiologist prior to her appointment and to bring a list of questions
  • I think it's very important that the cardiologist and other practitioners involved with this woman's care take the time to address all of her concerns and questions. She will have to understand what is involved with the follow up care, and also what she needs to do at home, especially given her age. Perhaps connecting with a cardiology nurse can help this woman.
    • Ongoing support is very important. At times we think everything is ok, however without the proper follow up things may not be as they seem. Having a pacemaker will need proper care and someone to advise on diet, exercise and ongoing care.
    • I agree, I hope that she can get the support she needs prior to, and after, her pacemaker procedure.
    • That is good advice. I find that as my in-law's get older they have more questions about medical stuff and require more guidance in the recovery period.
  • I did not realize that pacemaker's could be done on an outpatient basis
    • How long do the batteries last for in a pacemaker? How are they changed?
    • What would follow up be once having a pacemaker implanted ?
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