Bradyarrhythmias and cardiac pacemakers in the elderly

The aging population in the USA is growing exponentially, and the number of cardiac implantable electrical devices (CIEDs) is expected to increase proportionally. The most common presentations of bradyarrhythmias are sinus node dysfunction (SND), atrioventricular block (AVB), and carotid sinus hypersensitivity (CSH). These conditions frequently affect older patients, and pacemaker implantation is the therapy of choice. Few clinical trials have focused exclusively on the elderly; however, the age in most clinical trials of pacemakers ranges between 70 and 75 years. Evidence suggests elderly pacemaker recipients have similar outcomes to the age-matched general population. Thus, advanced age alone should not preclude the recommendation of pacing. The right ventricular (RV) lead has traditionally been placed in the RV apex. However, a trend has been toward conduction system pacing, specifically left bundle branch area pacing (LBBAP). Health care providers should be aware of end-of-life issues in pacing therapy. Proactive communication is crucial with very elderly patients or their legal guardians on topics related to withholding or withdrawing such treatment at the end of life.