To many of the 50,000 people in the UK each year fitted with a pacemaker, they are literally a life saver. Placed under the skin of the chest, they detect when the heart beats too slowly or erratically and instantly emit an impulse to correct the rhythm.
But pacemakers aren’t all good news. While correcting the heart’s rhythm can reduce the risks of breathlessness, fatigue, even fainting in some cases, they can also increase the risk of heart failure – one theory being that the heartbeat initiated by a pacemaker is less well co-ordinated than a normal beat, increasing the workload of the heart. Over time, this leads to changes in the heart muscle walls which can ultimately lead to heart failure.
The regular checks currently carried out on patients with pacemakers – around 500,000 in the UK – focus on ensuring the leads that connect it to the heart and the attached battery are working correctly. But research has found that checking on the patient’s heart function at the same time can detect early signs of heart failure and possibly save lives.
Symptoms of heart failure include shortness of breath and fatigue, but as pacemakers are often fitted in middle-aged or older people, they are easily dismissed as simply ageing.
The OPT-PACE trial, run by Leeds Teaching Hospitals NHS Trust and the University of Leeds, looked at whether checks on the heart itself could detect signs of heart failure, and, if found, whether this should simply be left to the GP to manage, or if patients should attend a specialist combined heart failure-pacemaker clinic.
The three-year study recruited 1,201 patients with pacemakers. Half were routinely screened for heart failure while the other half continued mostly to have equipment checks.
Dr Klaus Witte, a consultant cardiologist and senior lecturer in cardiology at the University of Leeds, who was one of the study leaders, says the results, published in the journal Nature Medicine, are potentially game-changing.
‘Screening finds about 30-40 per cent of those people [with pacemakers] have some degree of heart muscle weakness,’ Dr Witte tells Good Health, adding that some, at least, will go on to develop heart failure.
At rest, a normal heart should be between 60-100 beats per minute. When the heartbeat slows to a rate below 50 beats per minute – a condition called bradycardia – not enough oxygen-rich blood is pumped around the body, which can cause tiredness, breathlessness and fainting
‘There are a number of reasons for this,’ he explains. ‘The patients are generally older and may have other health problems, such as high blood pressure and previous heart attacks.
‘This makes the heart more vulnerable to the detuning [the walls of the heart are not contracting properly, so reducing efficiency] that one sees with a paced heartbeat,’ he says. ‘In addition, if the pacemaker is being used a lot, the detuned beats can lead to changes in the structure of the heart, with some areas of muscle getting thicker and some thinner, eventually leading to heart muscle weakness.
‘Overall, people with a pacemaker are at a higher risk of heart failure than people without one.’ Crucially, the trial found referring patients with signs of heart weakness to specialist clinics – where medication was reviewed and adjusted – rather than just sending results to their GP, meant they were less likely to be admitted to hospital over the subsequent five years with heart-related problems.
Dr Witte hopes the study will lead to a routine screening programme for pacemaker patients, using a heart scan and a blood test for a protein called B-type natriuretic peptide (BNP), raised levels of which can indicate heart failure, although more research is needed to prove this.
Ian Thompson, 77, a retired IT professional was among those invited to take part in the OPT-PACE trial. The grandfather-of-three, who lives with his wife Christine, 75, in Pontefract, West Yorkshire, suffered a heart attack in 2009 after a day when he says he felt ‘absolutely terrible’.
‘My left arm was tingling, I was feeling hot and being sick,’ says Ian.
After going to his local hospital, he was blue-lighted to Leeds General Infirmary where it was confirmed he’d had a heart attack and that his heart rate was below 50 beats per minute – at rest, a normal heart should be between 60-100 beats per minute. When the heartbeat slows to this extent – a condition called bradycardia – not enough oxygen-rich blood is pumped around the body, which can cause tiredness, breathlessness and fainting.
Ian had a pacemaker fitted under local anaesthetic in December 2009 – ‘a Christmas present’, he jokes.
‘My pacemaker was checked every six months and then annually to confirm it was operating correctly,’ he adds. ‘But my heart itself was never checked over the next seven years.’
In March 2016, Ian was offered the chance to take part in the OPT-PACE trial and his heart was checked with a 30-minute ultrasound scan.
‘The scan found I had a narrowed aortic valve,’ says Ian.
The valve controls the blood flow out of the heart – Ian’s was malfunctioning and blood was not flowing freely from the heart to the organs and tissues.
Left untreated it can lead to heart failure.
Ian says: ‘Although it wasn’t 100 per cent good news, it came as a relief to know that an issue had been detected and steps were being put into place to monitor the valve.’
Doctors upped his dose of bisoprolol – a drug that treats high blood pressure – to ease the strain on his heart.
But over the next few years Ian became more breathless, especially when climbing stairs.
Dr Mark Dayer, a consultant cardiologist and the clinical lead for heart failure at the Mater Private Hospital in Dublin
‘Christine also had to go to the post box for me because I struggled when taking a letter there, even though it was only 400 yards away,’ he says.
In December 2020 he underwent surgery to have his faulty aortic valve replaced with a synthetic one.
‘I was soon back to how I was a few years earlier,’ says Ian.
‘I was going to football matches to see my team Middlesbrough play. I could run up the stairs or go to the postbox again without struggling. It was such an improvement.’
Dr Witte says: ‘Heart failure is very gradual – people might think, ‘I’m old, I have a pacemaker, I’m breathless – this is just the way it is’. Our point with this study was that it might be, but you don’t know for sure.
‘A third of people with a pacemaker actually have insidious heart failure, and in many cases due to the pacemaker itself.’
Commenting on the study, Dr Mark Dayer, a consultant cardiologist and the clinical lead for heart failure at the Mater Private Hospital in Dublin, says: ‘I think screening using ultrasound scans is likely to be beneficial, but we need a larger trial, done in many centres using more robust methodology, to confirm the benefit.’
