Documented Symptomatic Bradycardia and Symptom Relief in Patients Receiving Permanent Pacemakers: An Evaluation of the Joint ACC/AHA Pacing Guidelines

Recently, emphasis has been placed on documenting symptomatic bradycardia (DSB) before pacemaker placement can be justified in some patients. This study was designed to judge whether DSB improved the likelihood of symptom relief after pacing in 93 patients who had symptoms prior to pacing. Patients with complete heart block (Group A) had excellent symptomatic relief with or without pre-pacemaker DSB (100% vs 94%, P = NS). Patients with other diagnoses (Group B) also had a high incidence of symptomatic relief after pacing, regardless of whether or not DSB was present pre-implant (28/30 (93%) vs 23/28 (82%) P = NS). When evaluated as a test to predict the response to pacing for Group B patients, spontaneously occurring symptomatic bradycardia was neither highly sensitive (55%) nor highly specific (71%). Moreover, while the ability of a positive test to predict resolution of symptoms after pacing was high (93%), the ability of a negative test to predict a poor outcome after pacing was low (18%). The absence of DSB should not rule out permanent pacing for symptomatic patients in any diagnostic group. Future pacing guidelines should be revised to offer additional detail regarding the influence of symptoms, extent of asymptomatic bradycardia, and results of provocative tests in determining which implants should be classified as definitely indicated.