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Cardiac Pacing for the Clinician FREE TO VIEW

Stanley S. Yormak, MD
Chest. 2002;122(3):1108. doi:10.1378/chest.122.3.1108
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By Fred M. Kusumoto and Nora F. Goldschlager, eds. Philadelphia, PA: Lippincott Williams & Wilkins, 2001; 512 pp; $99

I don’t mind sudden death, I just don’t want to be there when it happens.

Woody Allen

In this outstanding text on the prevention of sudden cardiac death by pacemaker control of arrhythmias, Kusumoto and Goldschlager have edited a book wherein each chapter vies for excellence. The writing is clear and direct, based on the authors’ hands-on experience with patients, and is replete with practical clinical suggestions for those involved with pacemaker implantation or follow-up care. Cardiologists and cardiothoracic surgeons will find much to reaffirm and enhance their daily activities; cardiology fellows, internists, and other clinicians will appreciate the in-depth discussions of the latest (1998) American College of Cardiology/American Heart Association guidelines for selecting those patients who will benefit from a pacemaker. Since the key to quality care of the pacemaker patient begins with the clinician’s thoughtful selection of the candidate, readers will appreciate the critical review of these standards and the recommendations for change offered by several authors.

The book is divided into the following four sections: “Pacing System and Modes of Function”; “Pacing Therapy for Specific Clinical Conditions”; “Evaluation and Follow-up of Pacing Systems”; and “Internal Cardiac Defibrillators.” The first section details the latest characteristics of pacing leads and pulse generators. The modes of pacemaker function are clearly delineated by reference to the North American Society of Pacing and Electrophysiology/British Pacing and Physiology Group code currently in use. The medical conditions appropriate for each pacing mode are clearly outlined, assisting the clinician in making suitable choices. The superb chapters on “Implant Techniques” and “Endocardial Lead Extraction” by Peter H. Bellot are models of clarity and completeness. In “Techniques for Temporary Pacing,” Mark Sheldon and the editors provide excellent instructions on transvenous lead placement, venous entry site selection, pitfalls to be avoided, and standards for careful follow-up.

Section II begins with the chapters “Sinus Node Dysfunction” and “Atrioventricular Block,” in which indications for pacing, selection of the best pacing mode (eg, AAI, VVI[R], or DDD[R]), and the pacemaker syndrome are discussed. The added value of rate-responsive pacing, an option now available in most pacing units, is reviewed. The editors discuss promising new pacemaker therapies in the next chapter, “New and Emerging Indications for Cardiac Pacing.” Pacing (possibly including biatrial pacing) is under investigation for stabilizing atrial fibrillation, may help some patients with hypertrophic obstructive cardiomyopathy, and may have a place in the treatment of advanced heart failure. Pacer therapy can be useful in treating reflex syncope, carotid sinus hypersensitivity, and vasovagal syncope. I especially liked the last chapter in this section, “Cardiac Pacing in the Critical Care Unit,” which is a superbly written treatise that includes pacemaker system complications and the diagnosis and treatment of malfunctions.

The chapter “Follow-up Management of the Paced Patient” in section III describes the high standards of care that are needed after the placement of modern pacing systems by stressing that proper functioning of the several pacemaker components must be checked at regular intervals. Multiprogrammability, an option that is available in modern pacing units, allows the physician to titrate the dose of pacing, much like medication doses are adjusted periodically. At each follow-up visit, one can interrogate and/or reprogram the pacemaker to optimize its parameters according to the individual patient’s needs, writing a new pacemaker prescription by waving the wand (pacemaker programmer) over the site of the implanted unit. The chapter “Environmental Effects on Cardiac Pacing Systems” spells out the multiplicity of dangers that may lurk near the pacemaker patient. Fortunately, most of these cause only transient pacer malfunction, but others (eg, transthoracic cardioverter/defibrillators and cancer radiation treatments) may cause permanent damage.

The marriage of pacemakers with internal cardioverter defibrillators (ICDs) has proved fruitful. The newer slimmed-down units permit the placement of leads transvenously, and of generators subpectorally. Identifying those patients at high risk for sudden death from ventricular arrhythmias is still the key to prevention. The chapter “Indications for Internal Cardioverter Defibrillators” in section IV enumerates the common and uncommon conditions associated with high risk of sudden death, fully discusses both invasive (electrophysiological studies) and noninvasive tests of risk assessment, and reviews several trials of primary and secondary prevention employing the combined pacer-ICD, with and without the use of drugs. Due consideration is given to drug-device and device-device (ie, implanted pacer and ICD) interactions that may be proarrhythmic, may increase the defibrillation threshold, or may trigger inappropriate shocks.

The indications for pacemaker use are rapidly expanding. New studies suggest that prophylactic placement in asymptomatic patients may decrease the likelihood of cardiac arrest and offer those patients with heart disease more years of enjoyable living. This superb volume will direct the way.

A merry heart maketh cheerful countenance: but by sorrow of the heart the spirit is broken.

Proverbs: 15:13




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