Pacemaker

Patient Information

Working together to improve the diagnosis, treatment

and quality of life for all those affected by arrhythmias

www.heartrhythmalliance.org
Registered Charity No. 1107496
Glossary

Arrhythmia An abnormal heart rhythm Contents

Atria The two upper chambers of the heart
The heart during
AV node Part of the electrical pathway between the atria and normal rhythm
the ventricles
What is a pacemaker?
Bradycardia A slow heart rate, normally less than 60 beats per
minute
Why do I need
Cardiologist A doctor who has specialised in the diagnosis and a pacemaker?
treatment of patients with a heart condition
How is the
Electrocardiogram (ECG) Records the electrical activity within pacemaker
the heart
implanted?
Heart block Electrical impulses are slowed or blocked as they
travel from the top to the bottom chambers of the heart What happens after
the pacemaker
Tachycardia An abnormally fast heart rate over 100 beats per is fitted?
minute

Ventricles The two lower chambers of the heart, providing Is there any
most of the pumping force equipment that
can affect
my pacemaker?

Important information
This booklet is intended for use by people who
wish to understand more about pacemakers.
The information comes from research and
previous patient experiences and offers an
explanation of the pacemaker procedure.

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The heart during normal rhythm

If your doctor has suggested that you have a The heart and
pacemaker fitted, it is because you have an normal conduction
abnormality in the electrical conduction system of
your heart. To help you understand this, it may be
useful for you to know how the electrical conduction
system in your heart works normally. Pulmonary veins

The heart is a muscle; its function is to pump blood Sinus

and oxygen around your body to all of your vital node

organs. A normal healthy heart usually beats in a

Atrium
regular fashion at around 50 to 100 times a minute.
AV node

It has four chambers, two at the top (the right and

Conducting
left atria) and two at the bottom (the right and left pathways
ventricles). The heart also has an electrical system, Ventricle
which sends impulses through the heart causing it © 2012 Arrhythmia Alliance
to contract and pump blood around the body.
Each normal heartbeat begins in the natural
pacemaker of the heart (the sinus sino-atrial or SA
node), which lies at the top of the right atrium. It
then travels across the two top chambers and down
through a small junction box (the atrio-ventricular or
AV node), which lies between the upper and lower
chambers. It then spreads rapidly through a special
conducting system through the ventricles causing
the heart to contract and pump.

Sometimes the electrical system in your heart does

not work as well as it should. This can cause the
heart to beat too slowly, irregularly, or the upper and
lower chambers to be out of sync. A pacemaker can
treat some of these abnormal heart rhythms.

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What is a pacemaker?

A pacemaker is a small device that is placed in

the chest to help control abnormal heart rhythms
(arrhythmias). It uses a battery and electronic
circuits connected to the heart by one or more wires
(leads) to prompt the heart to beat at a normal rate.

These leads are passed along a blood vessel to your

heart and the pacemaker box is usually implanted
under the skin in your upper chest. The pacemaker An example of a
can monitor your heart and produce electrical leadless pacemaker

impulses to treat abnormal heart rhythms.

Pacemakers may be single (one lead), dual (two leads) or triple (three leads) and
you will be fitted with the device appropriate for your particular condition.

Pacemakers are largely used to treat slow heart rhythms (bradycardia). One
type of pacemaker, the biventricular pacemaker or cardiac resynchronisation
therapy pacemaker, is increasingly being used to treat patients with heart
failure; this is not suitable for all but can be discussed with your doctor.

Recently leadless pacemakers have become available for use in specific

patients. These are very small devices that are implanted directly into the heart
and there are no leads required. Your doctor will know whether this is
something that would be suitable for you.

There are approximately 70,500 pacemakers implanted in the UK every year.

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Why do I need a pacemaker?

There are several different common conditions which cause the heart to beat
and the rhythm to be abnormal. These are:

Bradycardia
Bradycardia is a term that describes a number of different conditions in which
the heart beats at an unusually slow rate. If impulses are sent from the sinoatrial
node at a slow rate, or if the impulses are delayed as they travel through the
conduction system, the heartbeat will be slow.

The severity of and treatment for bradycardia depends on the area of the heart
affected. The goal of using a pacemaker to treat bradycardia is to keep your
heart rate at a level high enough to allow sufficient blood flow to the body.

Complete or intermittent heart block

Heart block accounts for about 60% of patients who have pacemakers
implanted. This is a condition where the AV node does not transmit the
electrical pulse from the top to the bottom of the heart. It may be complete or
partial. When this happens the heart usually beats very slowly and you may have
symptoms of dizziness or blackouts.

A pacemaker is required to restore a normal heart rate and correct the slowing
down of the natural electrical conduction tissue. This is most commonly due to
the conduction system 'wearing out with age', but can also occur as a congenital
(in-born) problem or as the result of a heart attack, infection, or particular
medications.

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Sick sinus syndrome
This is a condition where the natural pacemaker does
not function properly and results in your heart going
either too slowly or too fast or a combination of both.
An implanted pacemaker is used to support the slow
heart rate and medicine is usually given to control the
fast heart rhythms.
Pace and ablate for atrial fibrillation (AF)
Pacemakers are also used following a procedure called catheter ablation that
involves applying radiofrequency (special catheter procedure for uncontrolled
AF called 'pace and ablate') energy to the AV node in your heart, which
destroys the cells in this area. This means that the heartbeats can no longer
travel from the top to the bottom of the heart and a pacemaker is then used to
deliver electrical impulses to the heart. This procedure is performed when your
atrial fibrillation causes fast heart rates that cannot be controlled using standard
medication or other therapies. You can read more about the ablation procedure
in the Arrhythmia Alliance booklet: Treatment options for an arrhythmia.
Heart failure
Some people who experience heart failure (when the heart does not pump as
well as it should) can benefit from having a particular type of pacemaker, which
is known as a biventricular pacemaker or cardiac resynchronisation therapy.
This type of pacemaker usually involves three leads in the heart.

If you have heart failure, this therapy may improve some of your symptoms.
However, not all people who experience heart failure will benefit from this
treatment and careful assessment is needed before this type of pacemaker
is implanted.
His bundle pacing
The electrical pathways past the AV node split into right and left. Some patients
have an electrical delay on only one of these, and a pacemaker might be
appropriate to treat this. In practice, a pacemaker for His bundle pacing has two
leads: one on the atrium, and the other, which would normally be implanted on
the of the ventricle, is placed just below the AV node, in an area called the His
bundle, before the electrical conduction pathways split into two. This is a very
specific procedure which may only suit a small proportion of people.
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New leadless pacemaker
A new-style pacemaker is now available, designed to be placed directly in the
heart without the visible surgical pocket, scar and insulated leads required for
conventional pacemakers. The device offers a less invasive approach for patients
compared to traditional pacemaker procedures and leaves no visible sign of
a medical device under the skin, which can mean fewer post implant activity
restrictions and no obstructions to shoulder movement. The leadless pacemaker
is only suitable for a small number of people at this time. Your doctor will be able
to tell you if a leadless pacemaker is suitable for you.

Even with miniaturisation, the device battery is expected to have an average

lifespan of 10-12 years.

How is the pacemaker implanted?

On the day of your procedure, you will be taken to the cardiac pacing theatre or
catheter lab. Once you are in the pacing theatre, a nurse will check your details
and you will be asked to lie on a trolley or narrow operating table.

The procedure is not usually performed under a general anaesthetic, but you
may be given sedation, which will make you relaxed and sleepy.
Before the procedure starts, the doctor will clean the skin with some antiseptic
solution and inject some local anaesthetic under the skin just below your
collarbone.

This will numb the area and allow the doctor to pass a small lead or electrode
through a vein into your heart. You may have one, two or three leads inserted
depending on what type of pacemaker you need. The lead(s) are then connected
to the pacemaker box. This will usually be placed under the skin on your chest
wall. The area will then be closed with dissolvable or non-dissolvable stitches.

If your stitches need to be removed by your GP, practice nurse or district nurse
you will be informed before you leave hospital. The whole procedure should take
approximately 60 to 90 minutes.

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What happens after the pacemaker
is fitted?

Are there any risks associated with the procedure?

There are some small risks associated with having a pacemaker fitted.
Your doctor/specialist nurse will discuss these with you in more detail before
you sign your consent form. The most common risks are:

• A small risk of infection, bleeding and bruising to the pacemaker site.

• A small risk of lead displacement – the pacemaker lead can move

and would then need to be repositioned.

• A small risk of perforation of the lung during the procedure

(a pneumothorax) – this is often detected on the chest x-ray that
is performed following the pacemaker implant and can sometimes
rectify itself without treatment. Very occasionally a small drain may
need to be inserted through your side into your lung (in the space
between your ribs) to allow the punctured lung to re-inflate.
This is a simple procedure and the drain will be removed prior
to your discharge home.

After the procedure, you will be taken back to the ward. You will be asked to
lie in bed for a couple of hours before you can get up, eat and drink. Your heart
rhythm may be monitored for a while to make sure that the pacemaker is doing
its job, so you may be attached to an ECG monitor. As the wound can feel quite
bruised and sore, especially for the first day or two, it is recommended that you
take regular painkillers. It is important that you tell your nurse immediately if
you have any pain or discomfort. You may also be given some antibiotics to take
before and after the procedure to minimise the risk of infection.

The wound should be kept clean and dry until it has fully healed, although it is
fine to have a bath or shower after the first three or four days. Ask your nurse
for a protective dressing so that you can bathe without getting the wound wet.
Report any wound problems to your nurse.

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You will probably be allowed to go home the same or the next day provided your
pacemaker is checked, there are no complications and your doctor assesses
it is safe. Your pacemaker may be checked before you go home by a cardiac
physiologist. This check may involve the use of a special computer, called a
programmer, that can look at the device settings and make sure the pacemaker
is working properly, or a simple magnet check and an ECG will be sufficient.

This check takes about 15 minutes and can either be done on the ward or in
the pacemaker clinic. You will also have a chest x-ray to check lead positions
and make sure all is well following the implant procedure. Please ask the
physiologist or specialist nurse if you have any questions or worries about
the device. Depending on local policies, this check may happen a few hours after
having your pacemaker implanted, or a few weeks. In the latter, you will receive
an appointment letter to attend the pacemaker clinic in 4 to 8 weeks' time.

You will be given a pacemaker identity card which has details of the make and
model of your pacemaker. You should always carry this card with you. If you
require any further medical treatment in the future it is important that you show
this card to the health care professionals treating you.

Arm movements
Extra tissue will grow around the lead(s) in your heart after a few weeks,
which will prevent the wire(s) moving out of place. Patients should not interfere
with the area of the implant, but follow the instructions given until the first
follow up visit. As a general guide, you should not raise the arm on the same side
as the pacemaker above shoulder height for the first week. For the next two
weeks full, gentle shoulder movement is allowed. After three weeks you can
exercise gently. Once you have had your first pacemaker clinic check you will be
able to return to normal activity.

Wound site
Your wound site should take about six weeks to fully heal. Try to avoid wearing
tight clothing over the wound until it has healed completely to avoid excess
rubbing over the area.

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If you notice any redness, soreness or swelling of the area, or any signs of
bleeding or oozing from the wound, report this immediately to your implanting
centre as these may be a sign of wound infection.

You will probably be able to feel the pacemaker box under your skin as well
as other lumps close by. These are the leads that are attached to the box,
curled up beside the box under the skin. It is extremely important that you don’t
try to move the box or leads, but do let someone at the implant centre know if
they continue to bother you.

Will I feel the treatment from the pacemaker?

The device will be programmed to the best settings for you. This will be done
before you leave hospital, but the settings can be modified during your follow
up appointments in the clinic, as and when necessary.

You should not be aware of the pacemaker working, so if you feel body muscles
twitching you should report it to the implanting centre.
The pacemaker will not usually stop the heart from speeding up so if you had
fast palpitations before then they may continue. If this occurs the palpitations
are usually treated by medicine.

The pacemaker will be set to enable your own heart to work as much as possible
on its own and will only come in if your heart rhythm slows down to a certain
level. It works 'on demand', pacing the heart right before it becomes too slow,
so you don't experience any symptoms. If your heart rate is within normal
limits, the pacemaker monitors this activity, only acting when it starts to get
too slow. This allows your heart to work on its own, and saves battery,
preventing you from needing a battery replacement too early.

Will I be able to stop my tablets after I have my

pacemaker implanted?
This will depend on why you had the pacemaker implanted and your
cardiologist will advise you what to do.

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Safety issues
Can I still drive after I have my pacemaker implanted?
The Driving and Vehicle Licensing Agency (DVLA) have guidelines in relation to
patients who require a pacemaker and whether or not they are safe to drive.
There will be some restrictions, but these will vary depending on why you have
had your pacemaker fitted. It is very important that you discuss this with your
nurse, physiologist or doctor at your pacemaker centre who will explain this in
more detail.

You must inform the DVLA that you have had a pacemaker implanted it is also
strongly recommended that you inform your insurance company.

Can I exercise after I have my pacemaker fitted?

A certain level of exercise is needed to keep your heart healthy. You can take
part in most sports but it is advisable to avoid contact sports to minimise the risk
of damaging your pacemaker.

Following your initial recovery, it is advised to avoid strenuous activity in the first
four to six weeks after pacemaker implantation but then to partake in regular
healthy exercise. Please talk to your pacemaker clinic if you have concerns about
physical activity.

Pacemaker infections can be serious. If in between pacemaker checks you notice

redness, swelling or can see some of the metal it is very important you contact
your pacing clinic right away for them to review the pacemaker.

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Is there any equipment that can
affect my pacemaker?
Electromagnetic interference will not damage your
pacemaker but may temporarily interfere with its
settings whilst you are in contact with it.
Most mechanical and electrical devices that you use
in your normal daily activities will not affect your
pacemaker.

Household equipment such as ordinary radios,

fridges, cookers, remote controls, televisions,
electric razors, computers and microwaves etc. will
not affect your pacemaker as long as they are in
good working order.
If you buy an electrical appliance you may find that the instructions state
'do not use if you have a pacemaker'. This statement is normally put in to
cover the manufacturers and often is not necessarily applicable. It is best to
check with your pacemaker clinic for advice. Please note : DO NOT use an
AliveCor Kardia Mobile with a pacemaker, ICD, S-ICD, CRT or similar
implantable device.

If you feel dizzy or experience palpitations whilst using an electrical appliance,

you should move away from the appliance and phone the physiologist,
specialist nurse or doctor at the pacemaker clinic for advice.

Magnets and Mobile phones

Do not carry magnets or place a magnet over your chest. Keeping phones and
phone cases with magnetic clasps in your shirt or jacket front pocket is advised
against. Avoid carrying stereo or hi-fi speakers as they contain strong magnets
that can interfere with your pacemaker.

Some studies have shown that some mobile phones can affect the pacemaker
if held within six inches of the device. It is therefore recommended that you do
not keep a mobile phone in a coat or shirt pocket over the pacemaker. Keep
the handset more than six inches away from the pacemaker; ideally hold the
phone over the ear on the opposite side to the device.
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Shop doorway security systems
It is advised that you walk through shop doorway security systems at a normal
pace and not to wait around in this area.

Medical equipment / other hospital treatments

Most equipment used by your hospital or GP surgery will not cause any problems
to your pacemaker. However it is advised that you let medical and dental staff
know that you have a pacemaker.

It is safe for you to have x-rays, CT scans and mammograms. An increasing

number of pacemakers is now MRI conditional which means they have been
demonstrated to pose no known hazards in a specified MRI environment with
specified conditions of use. If you have any concerns, please speak to your
pacemaker clinic. If you're referred for a chest or brain MRI, the MRI
radiographers will contact the pacemaker clinic asking for advice, on whether
your pacemaker is or isn't MRI conditional.

Some electrical nerve and muscle stimulators (TENS units) may cause
interference with pacemakers but this depends on where they are being applied,
and, if any of these treatments are suggested to you then your pacemaker clinic
should be contacted for advice.

Travel
You can safely travel abroad with your pacemaker, but you are advised to show
the security staff your pacemaker identification card. Walk through the metal
detector archway if asked to do so, but the metal casing of the device may set
off the airport security alarm. The detector will not cause any harm to your
pacemaker provided you walk briskly through the arch.

Arc welding
Generally, this should be avoided but can be performed under special circumstances.
Please ask your pacemaker centre if you need further information on arc welding.

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Pacemaker clinic visits
Your pacemaker should be checked regularly and
you will be invited to attend your pacemaker clinic
as required. You will be seen at least once a year and
may be asked to attend more often if necessary.
You may also see the consultant cardiologist or their
registrar at your clinic visit.
During each clinic visit, the physiologist or specialist
nurse will examine your pacemaker using a special
programmer. This machine will allow them to
examine the settings and the battery life of your
device.
Special measurements are also done to assess the
state of the leads that connect the pacemaker to
your heart. If your condition has altered, changes
may be made to the pacemaker settings using the
special programmer. All the information is
confidentially stored in your records.
Your wound will also be checked and you may have other tests done. Please
also take this opportunity to ask any questions or let the medical team know if
you have any problems or worries.
Most pacemaker checks can now be performed remotely, using a device called a
home transmitter, or even your smartphone. Your local pacemaker clinic will be
able to advise you on this and help you set up this system if they believe it's
appropriate for you. The pacemaker activity and your heart rhythm are then
analysed by the clinic in exactly the same manner as when you physically attend
the clinic.

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Changing the pacemaker
Normally a pacemaker battery lasts between six and thirteen years. Your battery
will be checked at every visit to the pacemaker clinic and staff at the clinic will
be able to predict when you need a new pacemaker box and arrange for you to
be admitted at a convenient time for you. Don’t worry, it will not be allowed to
completely run down. for more information please visit What happens when my
pacemaker runs out of battery? by Cristiana Montiero https://
heartrhythmalliance.org/aa/uk/virtual-patient-education-platform

You will need to be admitted to hospital and the procedure is similar to having
your first pacemaker fitted, but it will not usually involve having new leads.

Contacting the pacemaker clinic

Most pacemaker clinics/support services run between 9am and 5pm Monday to
Friday. Ask staff at your implant centre about arrangements to contact them
outside these hours.

Please take your ID card with you whenever you go to hospital. It may also
be useful to contact your implanting centre for advice before you go into
hospital for any investigations or operations that are not associated with your
pacemaker. It is important to always mention to any doctors, nurses or dentists
that you have a pacemaker before undergoing any investigations or procedures.

This booklet has been written to support those with a pacemaker and their
carers, who struggle to find information on this device.
Without donations and fundraising, we would not be able to provide support
through our award-winning resources and helpline.

Please donate to support our vital work at

www.heartrhythmalliance.org
15
 Working together to
improve the diagnosis,
treatment and quality Finger on your Pulse: is our new library
of life for all those of educational video resources. Medical
affected by arrhythmias Experts share their knowledge and address
specific concerns and patients share their
experience living with the various
conditions and treatments.
www.fingeronyourpulse.org

"I was concerned about having a

pacemaker, the booklet gave me a step by
step guide and advice on some electrical
products to be wary of ” Jenny in Devon
+44 (0)1789 867 501

info@heartrhythmalliance.org Please remember that this publication

www.heartrhythmalliance.org provides general information. You should
always discuss and seek advice from your
Registered Charity No. 1107496
healthcare professional what is most
©Arrhythmia Alliance
©AF Association appropriate for you.
©STARS

Published September 2005 Acknowledgments: we would like to thank

Reviewed September 2021
all those who helped in the development
and review of this publication. Particular
endorsed by thanks are given to Dr Charlotte D’Souza,
Dr Cristiana Monteiro and Helen Eftekhari..

Founder and Trustee:

Trudie Lobban MBE, FRCP (Edin)

If you would like further information or would like to provide feedback please contact info@heartrhythmalliance.org.