Wednesday, June 7, 2023
This activity is intended for cardiologists, electrophysiologists, and other healthcare professionals involved in the management of patients with pacemakers.
The goal of this activity is to update clinicians on the implications of chronotropic incompetence (CI) and provide the latest management strategies for patients who have existing pacemakers and are who are experiencing CI.
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A 55-year-old man is seen for a follow-up appointment in the pacemaker clinic. Before he presented to the clinic with near-syncope and fatigue during exertion, he was a long-distance runner and competitive athlete with peak performance of a 6-minute mile. He underwent Holter monitoring that showed evidence of sinus node dysfunction and sinus pauses of over 4.5 seconds. He underwent a dual-chamber, dual-sensor, rate-modulated pacemaker implantation.
Following pacemaker implantation, he has not had further episodes of syncope but his lifestyle has been severely limited as his exercise tolerance declined due to sinus node dysfunction. He underwent multiple treadmill exercise tests and sensor parameters were successfully re-programmed to mimic normal intrinsic chronotropic function. His symptoms have markedly improved and at present, he runs a 7-minute mile and his only complaint is difficulty running on humid days and occasional Achilles tendon problems.
Most physicians who evaluate and treat patients with exercise intolerance, and fatigue or dyspnea on exertion, have faced similar clinical situations. While these symptoms are nonspecific and require consideration of a very wide list of differential diagnoses, chronotropic incompetence should be part of this differential diagnosis. The aim of this 2-part program is to discuss the pathophysiologic background, diagnosis, and treatment of chronotropic incompetence including pacemaker technology and sensors. We will also discuss several case studies from our pacemaker clinic to help understand some of the challenges we face in everyday practice.
First, however, it is important to review some of the basics of exercise physiology in order to better understand the pathophysiologic consequences, options and limitations of current therapy.
