Adaptive Rate Pacing Controlled by Right Ventricular Preejection Interval for Severe Refractory Orthostatic Hypotension

A 72-year-old African-American man with frequent recurrent syncope was found to have severe refractory orthostatic hypotension with concomitant supine hypertension. Pharmacotherapy was successful in controlling his supine hypertension but was unable to resolve his severe orthostatic hypotension. Temporary fixed rate tachypacing was only minimally effective in preventing syncope during upright tilt, while variable rate pacing based on degree of blood pressure fall was far superior. Following these observations, an adaptive rate pacing system controlled by right ventricular preejection interval was implanted (Precept DR Model 1200). The system adequately sensed the patient's fall in blood pressure when sitting or standing and augmented its rate accordingly, thus preventing syncope. While supine, the pacing rate fell to 60 ppm, thereby, avoiding an exacerbation of his concomitant supine hypertension. Over a 3-month follow-up period, he has had no further orthostatic or syncopal episodes. We conclude that adaptive rate pacing using right ventricular preejection interval may be an effective treatment for severe refractory orthostatic hypotension.