When A Pacemaker is the best choice

Aging column by Dr. Michael Gordon (08-02-2002)
Reprinted with permission from Toronto Star

“I am not sure what is happening to me,” my 88-year-old patient was saying. “All of a sudden, I felt faint and found myself on the floor of the apartment. Luckily, I only bruised my knee.”

Her daughter nodded when I asked if she had another events like this. She had felt a bit “woozy” but it passed in a few moments. I asked the daughter if she noticed anything about how her mother looked at the time and she said, “Maybe a bit pale, but that passed very quickly.”

I looked at her medications, none of which could be implicated in her symptoms. I arranged for her to have an electrocardiogram, which in the past had been normal, and a 24-hour Holter monitor, used to determine the heart rate (speed) and rhythm (whether it is beating evenly) over a prolonged period of time. She would have to wear this little machine like a tape recorder and push a button whenever she felt “woozy”.

Another patient was an 84-year-old man who almost blacked out while he was driving his car. A few days later he fell in the street and injured his wrist. He had suffered a few “spells” a day when he felt as if he might fall over. He could not explain his symptoms. The driving incident prompted the man’s physician to have the transport authorities revoke his driving licence, which upset the patient greatly as he insisted he was “OK” to drive. The physician wondered about “seizures” and sent him for an EEG (electroencephalogram to measure his “brain waves”) to try and diagnose seizures as the cause of his “blackouts”. After a geriatric medicine consultation, a Holter monitor was also ordered.

The symptoms experienced by these two patients are commonly associated with an abnormal heart rhythm, which momentarily diminishes the blood’s circulation to the brain. This may be enough for the person to suddenly feel dizzy or “black out”. Sometimes it appears a “seizure” has occurred. Sometime the person feels very little, but just falls for no apparent reason. Sometimes the person feels little, but falls for no apparent reason. Older people tend to accept these falls as part of aging.

In cases such as these, part of the investigation often would include a Holter monitor as a way for people living at home to have their heart rhythm recorded for a prolonged period, usually 24 hours. If the monitor test is successful, the diagnosis of an abnormal heart rhythm being the cause of the symptoms is pretty conclusive.

In both of the patients referred to above, the Holter monitor showed the heart rate fell to a very slow speed (both of them recorded about 30 beats per minute instead of the 60 or more that is the norm). This indicated that the electrical circuit which keeps the heart beating at the right speed was not working properly. In such situations, a patient has to be fitted with a pacemaker, which provides the electrical stimulation to keep the heart beating at the appropriate speed.

Each of the patients responded differently to the suggested treatment. The man with the driving problem immediately agreed to have a pacemaker fitted after I used the analogy of a car -- when the battery dies, you don’t throw away the car, you instead put in a new battery. A week after he got the pacemaker, he said he was feeling much better. He was told he could re-apply for his driving licence and that in all likelihood could redeem it.

The woman initially refused to have a pacemaker, saying she was too old for heart surgery and that she didn’t want to take the risk. I asked her whether, if she fell and broke a hip, she would agree to have it repaired or accept immobility for the rest of her life. She looked at me and said, “Of course, I would have my hip fixed. Remember, I had hip surgery nine years ago for arthritis and it was almost a miracle how the pain went away and I was able to walk again.” So, I asked, why not agree to a simple procedure, which would probably not even require hospital admission, or at most a day or two, and should eliminate the risk of fainting, falling and injury? She laughed and said, “You are right.”

Her pacemaker was put in less than a week later and she has had no further faints or falls.

Of the miracles of modern medicine that benefit many older persons with very little risk, the pacemaker ranks high in my estimation.

Dr. Michael Gordon is a geriatrician, vice-president of medical services and head of geriatrics at Baycrest Centre for Geriatric Care. He is co-author of Parenting Your Parents (2002, Dundurn Press).

Dr. Michael Gordon is Vice-President of Medical Service at Baycrest, a professor of Medicine at the University of Toronto, and a member of the National Advisory Council on Aging.

These columns appeared in The Toronto Star in 2001 and 2002 and are reprinted with permission.