Palpitations following pacemaker insertion

Mrs RW is a 65-year-old woman who presents for a scheduled follow-up appointment one month after elective implantation of a permanent pacemaker. She is married with adult children and enjoys painting art outdoors. Today, you do not expect any issues because you have received the report of her postimplantation device interrogation, which showed a normal functioning dual-chamber pacemaker. Her indication for pacing was symptomatic Mobitz type II atrioventricular block with a ventricular rate of 30 beats per minute. Before pacemaker implantation, she had reported frequent episodes of presyncope but no syncope. She has a past medical history of type 2 diabetes mellitus, which is controlled with metformin 1000 mg daily.

In your consultation, Mrs RW reports new episodes of presyncope over the preceding week. The episodes lasted between 15 minutes and two hours and occurred while she was sitting or standing. There was no association with exertion. You enquire about palpitations, and she quickly agrees that she has felt her heart racing. She denies having chest pain or dyspnoea.

Picture credit: © WaveBreakMediaMicro/Dollar Photo Club. Model used for illustrative purposes only.