Time to pacemaker insertion in older adults: A perspective on mortality and functional outcomes

Pacemaker insertion is common in older adults, yet the implications of procedural delays remain unclear. Nguyen and colleagues reported that longer time to implantation was associated with increased mortality over nearly five years. While this contribution is valuable, several methodological considerations warrant scrutiny before causal interpretations can be drawn. Infection may drive delay rather than result from it, as suggested by elevated neutrophils in the delayed group. Deconditioning, proposed as the mediating mechanism, was not directly measured. Residential aged care admission as a proxy for functional decline is influenced by social and caregiver factors independent of patient function. The 48‑hour threshold appears data‑driven rather than clinically justified. Finally, the absence of baseline frailty measures leaves residual confounding. Addressing these considerations would strengthen causal inference and refine clinical strategies.