A 79-Year-Old Woman With a Pacemaker and High Atrial Rates

Jeff S. Healey, MD, MSc, FRCPC; Jonathan P. Piccini, MD, MHS, FACC; Christian T. Ruff, MD, MPH

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March 22, 2019

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Physical Examination and Workup

Upon physical examination, the patient's heart rate is regular at 60 beats/min. Her blood pressure is 135/75 mm Hg. No crackles on auscultation of the chest are heard. The jugular venous pressure is 1 cm above the sternal angle, and no peripheral edema is noted. No vascular bruits are observed, and the heart sounds are normal except for a soft S4 sound. The cardiac apex is neither displaced nor sustained. The left pectoral pacemaker site is well healed, with no bruising of the skin. Her weight is 130 lb (59 kg).

A repeat echocardiogram reveals borderline left ventricular hypertrophy, with a left atrial volume index of 35 mL/m2. Left ventricular systolic function is normal, while diastolic functional assessment suggests impaired relaxation. Valvular function is normal. Fasting blood sugar and blood glucose levels are within normal limits.

Complete blood count findings are within the reference range, as are standard coagulation tests. Serum electrolyte levels are normal, and the serum creatinine level is 118 µmol/L. A 12-lead ECG shows sinus rhythm at 60 beats/min with atrial sensing and intermittent ventricular pacing. Interrogation of her pacemaker shows three episodes of atrial high-rate episodes, lasting 8 minutes, 12 minutes, and 33 minutes in duration.

These were detected over a 1-week period 6 months ago and are the only such episodes detected since the time the patient's pacemaker was implanted. Device and lead function are normal, and she has an estimated 2 years of remaining battery life. She is paced only 10% of the time in the atrium at 60 beats/min and is paced 40% in the ventricle.

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