Simplified Interpretation of Pacemaker ECGs An Introduction,
1st Edition
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Foreword
Within the past three decades, pacemakers have evolved from
fixed-rate, single-chamber units to incredibly sophisticated dual-
chamber devices that are capable of many different pacing modal-
ities, that provide physiologic response to exercise or stress using a
variety of sensors, and that also provide various diagnostic capabili-
ties. These advances in technology have been accompanied by an
inevitable increase in the complexity of ECG interpretation of pace-
maker-generated rhythms. For those not directly involved in the
management of pacemakers, the attainment of the skills needed to
interpret pacemaker ECGs has been a daunting task.
With the availability of Simplified Interpretation of Pacemaker ECGs,
a previously daunting task is now simple and painless. The reader
is led step-by-step through all of the information needed to interpret
pacemaker ECGs. After a brief refresher course on basic ECG inter-
pretation, the reader is provided with an overview of the conduction
system of the heart. The hardware associated with pacing is then
reviewed, followed by an explanation of sensing and pacing function
of pacemakers. Next is an explanation of the most common pacing
modalities in a fashion that is simple to understand, yet thorough
enough to make pacemaker ECG interpretation easy. This is followed
by a very useful section dealing with miscellaneous topics such as
automatic threshold determination, electromagnetic interference,
and the use of pacing for indications other than bradycardia. The
text ends with a series of case studies that brings together all of the
information learned and provides the reader with a self-assessment
of the topics that may need additional review.
The text is replete with schematic illustrations, charts, and ECG
recordings that greatly enhance the learning experience. Further-
more, the reader is frequently challenged to answer questions that
reinforce the material learned in a particular section.
Dr. Hesselson has succeeded admirably in distilling a potentially
confusing body of knowledge into a simple-to-understand and palat-
able programmed text that is fun to go through. He could have
v
entitled the book Pacemakers for Dummies. With the few hours of time
needed to go through this book, no one need feel like a ‘‘dummy’’
when faced with a pacemaker ECG.
Fred Morady, MD
Professor of Medicine
Director, Clinical Electrophysiology Laboratory
University of Michigan Medical Center
Ann Arbor, MI
vi
Preface
It was 12 years ago that I began working in my first job out of
college as a clinical pacemaker research engineer at Beth Israel
Medical Center in Newark, NJ. Not having much experience with
ECG interpretation I was given a basic text to read and learn. Soon
after that I was ready to begin learning pacemaker ECG interpreta-
tion, and was surprised to find out that a similar basic text solely
dedicated to pacemaker ECGs did not exist. Instead I was given
technical manuals, proprietary ‘‘learning manuals’’ from various
pacemaker manufacturers, and a pacemaker with a heart rhythm
simulator to work with. For an engineer these were not difficult to
use and understand.
Having since gone to medical school and trained as an internist,
cardiologist, and now cardiac electrophysiologist, I have found that
this lack of a basic pacemaker ECG interpretation text still exists.
This book intends to change that. It has been written with a few
thoughts in mind: ‘‘what would I have wanted in my hands when I
was just beginning to learn pacemaker ECGs?’’ and ‘‘keep it as simple
as possible so that not only an engineer, but also nurses, technicians,
and even physicians can follow.’’ I have attempted to concentrate
on the ideas that I found best in my experience. As such, there is
an enormous emphasis placed on knowing a few basic parameters
of the pacemaker system and their relation to the patient’s native
heart rate and integrity of conduction from atrium to ventricle. The
book requires that one already have a working knowledge of basic
non-pacemaker ECG interpretation. Once studied, even fairly diffi-
cult pacemaker ECGs should be appropriately interpreted.
As one will see when reading the text, the figures are not num-
bered. Each image is placed in direct proximity to the text that
refers to it. Also, there are fill-in-the-blank questions, with answers
in boldface directly below, following most paragraphs. This ‘‘pro-
grammed teaching’’ style is done to emphasize salient points in the
preceding text. In order to help maintain this format, there may
vii
be empty areas on some pages. One may optimally use these spaces
for study notes.
Some pacemakers have functions that are peculiar to the individ-
ual model and that may affect the ECG. Such details are not empha-
sized here. Consulting the technical manual that comes with each
pacemaker, the local pacemaker ECG guru (EP attending, nurse,
whoever), or pacemaker manufacturer technical service/sales repre-
sentative is helpful in this regard. Good luck!
viii
Acknowledgments
The following were instrumental influences, without whom this
book would not be possible: Victor Parsonnet, MD; Alan D. Bernstein,
EngScD; Donna Neglia, RN; Esther Schilling, RN; Ralph Gallagher;
Thomas M. Bashore, MD, Robert Sorrentino, MD; Ruth Ann Green-
field, MD; and Matthew Flemming, MD.
ix
Contents
Foreword............................................................................................. v
Preface .............................................................................................. vii
Acknowledgments ............................................................................ ix
Section I
The Basics
Chapter 1. Basic ECG Refresher ...................................................... 3
Chapter 2. What Is a Pacemaker? .................................................. 21
Chapter 3. Pacemaker System and Cardiac Anatomy .................. 25
Chapter 4. The Hardware............................................................... 27
The Pacemaker Generator ...................................................... 28
The Pacemaker Lead ............................................................... 31
The Pacemaker Programmer .................................................. 34
The Pacemaker Magnet........................................................... 39
Chapter 5. Electronics 101.............................................................. 41
The Electrogram ...................................................................... 49
Chapter 6. Sensing and Sensitivity ................................................. 51
Chapter 7. Pacing and Capture...................................................... 55
Chapter 8. Rate Versus Interval ..................................................... 61
Chapter 9. The Code and Mode.................................................... 65
Section II
The Modes
Chapter 10. VVI Pacing................................................................... 73
VVI Timing ............................................................................... 75
Rate Modulation ...................................................................... 81
Magnet Mode (VOO) .............................................................. 82
Chapter 11. AAI Pacing .................................................................. 85
AAI Timing ............................................................................... 87
xi
Rate Modulation ...................................................................... 91
Magnet Mode (AOO).............................................................. 92
Chapter 12. DDD Pacing ................................................................ 95
DDD Timing............................................................................. 97
Upper Rate Behavior ............................................................. 113
Pacemaker-Mediated Tachycardia ........................................ 115
Mode Switching...................................................................... 117
Rate Modulation .................................................................... 118
Magnet Mode (DOO)............................................................ 120
Chapter 13. VDD Pacing............................................................... 121
VDD Timing ........................................................................... 124
Upper Rate Behavior/Mode Switching................................ 133
Magnet Mode (VOO) ............................................................ 135
Chapter 14. DDI Pacing................................................................ 137
DDI Timing ............................................................................ 139
Rate Modulation .................................................................... 151
Magnet Mode (DOO)............................................................ 153
Chapter 15. DVI Pacing ................................................................ 155
DVI Timing............................................................................. 158
Rate Modulation .................................................................... 167
Magnet Mode (DOO)............................................................ 168
Section III
Unusual Pacing Situations and Alternate
Applications of Permanent Pacing
Chapter 16. Unusual Pacing Situations ....................................... 171
Diagnostic Pacing Modes ...................................................... 172
Pacing to Prevent Atrial Fibrillation .................................... 174
Transcutaneous Pacing.......................................................... 175
Automatic Threshold Determination................................... 176
Diagnosis of Myocardial Infarction ...................................... 177
Effects of Electric Cautery on Pacing................................... 179
Chapter 17. Alternate Applications of Permanent Pacing......... 181
Pacing for Hypertrophic Obstructive Cardiomyopathy ...... 182
Pacing for Ventricular Tachycardia...................................... 184
Pacing for Heart Failure........................................................ 186
Pacing for Syncope ................................................................ 188
xii
Section IV
Case Studies
Chapter 18. Case Studies Part A .................................................. 193
Case Studies 1 through 7
Chapter 19. Case Studies Part B .................................................. 205
Case Studies 8 through 43
Index............................................................................................... 277
xiii
Section I
The Basics
Chapter 1
Basic ECG Refresher
3
4 • SIMPLIFIED INTERPRETATION OF PACEMAKER ECGS
It is strongly suggested that one master basic non-pacemaker
electrocardiograph (ECG) interpretation before beginning pace-
maker ECG analysis. What follows in this section is not meant to
provide that skill. Rather this ‘‘refresher’’ is meant to highlight some
areas of ECG interpretation that may be pertinent to understanding
pacemaker rhythms and device function. Those who already feel
comfortable in their non-pacemaker ECG interpretative skills should
proceed beyond this section.
ECG ‘‘ANATOMY’’
The sinus or ‘‘SA node’’ is the heart’s own pacemaker that,
in normal circumstances, initiates the heartbeat. From this native
activation first the right (RA) and then left atrium (LA) are stimu-
lated to contract. This activation is noted on the ECG as a ‘‘P wave.’’
Atrial electrical activation is represented on the ECG by
the .
The structure in the RA that normally initiates the heartbeat is
the .
P WAVE
SA or SINUS NODE
ECG Refresher • 5
After atrial activation, the ‘‘atrioventricular (AV) node,’’ fol-
lowed by the ‘‘His bundle,’’ and then the ‘‘left (LBB)’’ and ‘‘right
(RBB) bundle branches’’ become electrically stimulated. This results
in left (LV) and right (RV) ventricular contraction, and is noted on
the ECG as a ‘‘QRS’’ complex.* The ventricles then relax after
contraction. This event, ‘‘ventricular repolarization,’’ is noted on
the ECG as the ‘‘T wave.’’
The QRS complex on an ECG represents electrical acti-
vation.
Ventricular is seen on the ECG as the T wave.
VENTRICULAR
REPOLARIZATION
*QRS is a generic term that refers to the ventricular complex on the surface ECG. Not every
QRS complex has all three components: Q wave (the initial negative deflection), R wave (the
initial positive deflection), and S wave (negative deflection after an R wave). In some cases
there is a second positive component termed R′.
6 • SIMPLIFIED INTERPRETATION OF PACEMAKER ECGS
HOW FAST IS IT?
An easy method for determining how fast the heart rate is, on
a standard speed ECG grid, is to find a QRS complex on a heavy
grid line and note where the next QRS falls. The subsequent heavy
grid lines after the first correspond to heart rates of 300, 150, 100,
75, 60, and 50 beats per minute (bpm), respectively. By memorizing
this grid line progression, quickly approximating heart rate becomes
simple!
The heart rate when a second QRS complex occurs four heavy grid
lines after the first is .
A heart rate of 150 bpm would occur when two QRS complexes
occur heavy grid lines apart.
75 bpm
2
