Clinical and electrocardiographic predictors of perfusion impairment in symptomatic bradycardia requiring permanent pacemaker implantation

Symptomatic bradycardia can lead to systemic hypoperfusion and hemodynamic instability, particularly in patients with advanced conduction system disease. This study aimed to identify factors associated with perfusion impairment in patients experiencing persistent symptomatic bradycardia who required permanent pacemaker implantation. In this single-center retrospective observational study, 299 patients who underwent pacemaker implantation between December 2021 and June 2025 were screened, resulting in the inclusion of 166 patients with persistent symptomatic bradycardia. Patients were stratified based on the presence of perfusion impairment, defined using specific clinical, biochemical, and organ-specific criteria. We analyzed clinical, laboratory, electrocardiographic, and echocardiographic parameters obtained prior to pacing. Perfusion impairment was identified in 70 patients, who were older and exhibited lower heart rates and blood pressures, elevated lactate levels, a higher incidence of renal dysfunction, and increased inflammatory markers. Multivariable analysis revealed that age (odds ratio OR 1.097; p = 0.001), heart rate (OR 0.910; p = 0.022), and high-grade atrioventricular (AV) block (OR 7.546; p = 0.002) were independently associated with perfusion impairment. Receiver operating characteristic (ROC) analysis demonstrated moderate discrimination for age and heart rate, while the multivariable model displayed improved discrimination. Our findings indicate that advanced age, lower baseline heart rate, and high-grade AV block are correlated with perfusion impairment in patients with persistent symptomatic bradycardia requiring pacemaker implantation. Early identification of this high-risk subgroup may facilitate timely monitoring and intervention.