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Heart Failure: Should I Get a Pacemaker (Cardiac Resynchronization Therapy)?
You may want to have a say in this decision, or you may simply want to follow your doctor's recommendation. Either way, this information will help you understand what your choices are so that you can talk to your doctor about them.
Heart Failure: Should I Get a Pacemaker (Cardiac Resynchronization Therapy)?
Get the facts
- Get a pacemaker for heart failure.
- Don't get a pacemaker for heart failure.
A pacemaker for heart failure is used for cardiac resynchronization therapy (CRT). This type of pacemaker is different from pacemakers used to treat other heart rhythm problems, such as atrial fibrillation and bradycardia. This topic is only about pacemakers for heart failure. You might hear it only called cardiac resynchronization therapy, or CRT.
Key points to remember
- A pacemaker for heart failure, also called cardiac resynchronization therapy or CRT, can help you feel better so you can do your daily activities. It also may help keep you out of the hospital and help you live longer.
- If you get a pacemaker, you still need to take medicines for heart failure. You'll also need to follow a healthy lifestyle to help treat heart failure. This may include watching how much fluid you drink, eating healthy foods that are low in salt, and not smoking.
- Heart experts have guidelines about who might need a pacemaker. Talk to your doctor about the reasons that you might need one. For example, a pacemaker may be a good choice if you have moderate or severe heart failure and your heart's ventricles don't pump at the same time.
- A pacemaker sends electrical pulses to your heart to help it work better. You can't feel the pulses.
- There can be problems from having a pacemaker placed in your chest. The wires (called leads) that connect the pacemaker to your heart can move from the spot where they were placed. You could get an infection where the pacemaker was placed. Or the pacemaker or leads might not work.
When you have heart failure, the lower chambers of your heart (the ventricles) aren't able to pump as much blood as your body needs. Sometimes, the ventricles also don't pump at the same time.
Cardiac resynchronization therapy (CRT) uses a special type of pacemaker called a biventricular pacemaker (say "by-ven-TRICK-yuh-ler") to treat heart failure. This pacemaker sends electrical pulses to make the ventricles pump at the same time. This can improve your symptoms of heart failure.
A biventricular pacemaker sends signals to both ventricles. The pacemaker connects to three thin wires, called leads. The leads go into different chambers of your heart. If there is a problem with your heartbeat, the pacemaker sends a painless signal through the leads to fix the problem. The pacemaker also can speed up your heart if it is beating too slowly.
In some cases, you may get a pacemaker for heart failure that is combined with a device to shock your heartbeat back to a normal rhythm if it is dangerously fast. The device is called an implantable cardioverter-defibrillator, or ICD. It can prevent sudden death.
Your doctor will put the pacemaker in your chest during minor surgery. You will not have open-chest surgery. You probably will have local anesthesia. This means that you will be awake but feel no pain. You also will likely have medicine to make you feel relaxed and sleepy.
Your doctor makes a small cut (incision) in your upper chest. In some cases, the pacemaker can be placed lower in the chest. This would allow you to wear clothing with a lower neckline and still keep the scar covered. The doctor puts the leads in a vein and threads them to the heart. Then your doctor connects the leads to the pacemaker. Your doctor programs the pacemaker and then puts it in your chest and closes the incision.
It can take about 2 to 3 hours to place the pacemaker.
Most people spend the night in the hospital, just to make sure that the device is working and that there are no problems from the surgery. But sometimes the procedure is done as an outpatient procedure, which means you don't need to stay overnight in the hospital.
You may be able to see a little bump under the skin where the pacemaker is placed.
- You have class III or class IV heart failure. This means that you have trouble doing everyday activities or you can't do them at all. Activity makes you very tired and short of breath, or you have pain or other problems.
- You are taking medicines for heart failure, but you still have symptoms like being very tired and short of breath.
- You have an ejection fraction of 35% or less. Ejection fraction is a measure of how much blood your left ventricle pumps. A normal ejection fraction is 55% or more.
- Tests show that your heart's ventricles are not beating at the right time. These tests may include an electrocardiogram (EKG, ECG) test, an echocardiogram, or an electrophysiology study.
A pacemaker can help you feel better so you can be more active. It also can help keep you out of the hospital and help you live longer.
- A large study found that 19 out of 100 people who were treated with a pacemaker for heart failure had to go into the hospital during the study because of heart failure. But 27 out of 100 people treated with medicine alone had to go into the hospital for heart failure.3
- In the same study, 13 out of 100 people who got a pacemaker for heart failure died during the study, compared with 16 out of 100 who got only medicine.3
- The combination of a pacemaker and an ICD (implantable cardioverter-defibrillator) can also help people live longer and stay out of the hospital.4
A pacemaker also can help your heart pump better by changing the shape of your heart. In heart failure, the left ventricle often gets too big as it tries to make up for not pumping well. Using a pacemaker may reverse this.
There are several risks to getting a pacemaker. But risks vary for each person. The chance of most problems is low.
The procedure to implant a pacemaker is safe, and most people do well afterward. You will see your doctor regularly to check your pacemaker and make sure you don't have any problems.
During the procedure. If problems happen during the procedure, doctors likely can fix them right away.
- A lung could collapse (pneumothorax). This happens if air builds up in the space between the lung and the chest wall. But a pneumothorax can be treated and people recover well. This might happen about 1 time out of 100. So about 99 times out of 100, no problems happen.5
- Serious problems during the procedure are very rare. These problems include heart attack, stroke, or the need for an emergency surgery. These problems might happen 1 time out of 1000.6
- The pacemaker might not be able to be implanted for several reasons, such as when a vein near the left ventricle is too small, too wide, or too hard to reach to allow a lead to be placed. Sometimes the chest or heart may be too big to place a lead. The chance that a doctor can't place the pacemaker is about 8 out of 100. That means the pacemaker can be placed 92 times out of 100.5
After the procedure. Problems after the procedure can be minor, like mild pain, or serious, like an infection. But your doctor can solve most of these problems. And most people do not have long-term issues with their pacemakers.
- Pain, bleeding, or bruising soon after the procedure.
- Infection in your chest near the pacemaker. An infection might happen about 1 time out of 100. This means that about 99 times out of 100 there is no infection.2
- The pacemaker or leads might not work. This might happen about 7 times out of 100. So 93 times out of 100, the pacemaker and leads do work.7
- A lead might move out of place. This might happen up to 9 times out of 100. So about 91 out of 100 times, the lead stays in place.7
Daily precautions. Some activities and situations can interrupt the signals sent by the pacemaker to the heart. You may need to adapt some of your activities. If you have a pacemaker, follow your doctor's specific instructions about care and precautions.
Compare your options
What is usually involved?
What are the benefits?
What are the risks and side effects?
- The doctor will numb the area so you won't feel pain. (This is not open-chest surgery.)
- It can take up to 2 to 3 hours to place the pacemaker.
- You may spend the night in the hospital to make sure that the device is working and that there are no problems.
- You will need regular checkups to make sure that the pacemaker is working and to adjust the pacing, if needed.
- You still need to take medicines for heart failure.
- You still have to eat healthy foods and exercise as your doctor advises. You also may need to limit salt and fluids.
- A pacemaker can help you feel better so you can be more active.
- It can help keep you out of the hospital and help you live longer.
- It can help your heart pump better by changing the shape of your heart. In heart failure, the left ventricle often gets too big as it tries to make up for not pumping well.
The risks from surgery are usually low. But they may be different for each person. Here are some possible risks:
- Problems can happen during the procedure to place the pacemaker or soon after the procedure. One example is a lung collapsing.
- The doctor might not be able to place the pacemaker. For example, a vein could be too small to place a lead.
- There might be problems with the pacemaker. Examples include an infection or leads that don't work.
- Some devices with strong magnetic or electrical fields could stop the pacemaker from working. You need to avoid MRI machines, battery-powered cordless power tools, and CB or ham radios. But most everyday appliances and electronic devices are safe.
- You will need surgery to replace the battery, which lasts 8 to 10 years.
- You take medicines for heart failure. Your doctor may change the type or dose of your medicines.
- You have to eat healthy foods and exercise as your doctor advises. You also may need to limit salt and fluids.
- You may have to see your doctor often to check your symptoms and how your medicine is working.
- You won't have the risk of infection or other problems from the surgery.
- You won't have to think about safety around devices that could stop your pacemaker from working.
- Your symptoms could get worse. This would limit your ability to do your daily activities.
- If your heart failure gets worse, you may have to go into the hospital a lot.
- You might not live as long as you could if you had a pacemaker.3
Personal stories about getting a pacemaker for heart failure
These stories are based on information gathered from health professionals and consumers. They may be helpful as you make important health decisions.
I have a hard time getting my chores done around the house or going grocery shopping. I get really short of breath after walking for a few minutes. My doctor says a pacemaker could help me feel better.
Jack, age 66
I had a heart attack a while ago, and now I have heart failure. But my doctor said it's pretty mild. I can still work and take my daily walks with no problem. I don't think I need a pacemaker. I'll keep taking my medicine and following my diet.
Serena, age 55
My girlfriends and I go on a big trip every year. We visit museums and take long walks. But my heart failure has been getting worse. It's harder for me to keep up with them, because I get so tired. My doctor said maybe I should get a special pacemaker for people with heart failure. I'm going to get one, because I want to do what I can to stay active.
Patty, age 72
My heart failure is getting a little worse. I can't play a whole round of golf anymore. My doctor and I talked about a pacemaker. But I'm scared of having one of those. I don't like the idea of wires in my heart. I told my doctor that I want to keep taking my medicine and follow my diet to see if that helps. If my heart failure gets worse, I'll look again at getting a pacemaker.
Ralph, age 64
What matters most to you?
Your personal feelings are just as important as the medical facts. Think about what matters most to you in this decision, and show how you feel about the following statements.
Reasons to get a pacemaker
Reasons not to get a pacemaker
I want to feel better so that I can do my daily activities.
I'm not having too much trouble doing my daily activities.
I don't mind having a device in my chest.
I don't like the idea of having a device in my chest.
My medicines aren't controlling my symptoms anymore.
My symptoms aren't getting worse.
I'm not worried about risks from surgery, because they're small.
I don't want to take a chance that something could go wrong during surgery.
My other important reasons:
My other important reasons:
Where are you leaning now?
Now that you've thought about the facts and your feelings, you may have a general idea of where you stand on this decision. Show which way you are leaning right now.
Getting a pacemaker
NOT getting a pacemaker
What else do you need to make your decision?
Check the facts
I don't need a pacemaker if I have mild heart failure and can still do my daily activities.
- TrueYou're right. You don't need a pacemaker for mild heart failure. A pacemaker may be a good choice if you have moderate or severe heart failure and have trouble doing your daily activities.
- FalseSorry, that's not right. You don't need a pacemaker for mild heart failure. A pacemaker may be a good choice if you have moderate or severe heart failure and have trouble doing your daily activities.
- I'm not sureIt may help to go back and read "Get the Facts." You don't need a pacemaker for mild heart failure. A pacemaker may be a good choice if you have moderate or severe heart failure.
A pacemaker could help me stay out of the hospital and live longer.
- TrueThat's right. A pacemaker for heart failure can help you stay out of the hospital and live longer.
- FalseSorry, that's not right. A pacemaker for heart failure can help you stay out of the hospital and live longer.
- I'm not sureIt may help to go back and read "Get the Facts." A pacemaker for heart failure can help you stay out of the hospital and live longer.
If I get a pacemaker, I still need to take medicines for heart failure and follow a healthy lifestyle.
- TrueYou're right. You still need to take your medicines for heart failure and follow a healthy lifestyle. This may include watching how much fluid you drink, eating healthy foods that are low in salt, and not smoking.
- FalseSorry, that's not right. You still need to take your medicines for heart failure and follow a healthy lifestyle. This may include watching how much fluid you drink, eating healthy foods that are low in salt, and not smoking.
- I'm not sureIt may help to go back and read "Get the Facts." You still need to take your medicines for heart failure and follow a healthy lifestyle.
Decide what's next
Do you understand the options available to you?
Are you clear about which benefits and side effects matter most to you?
Do you have enough support and advice from others to make a choice?
How sure do you feel right now about your decision?
Use the following space to list questions, concerns, and next steps.
Here's a record of your answers. You can use it to talk with your doctor or loved ones about your decision.
|Primary Medical Reviewer||Rakesh K. Pai, MD, FACC - Cardiology, Electrophysiology|
|Specialist Medical Reviewer||Stephen Fort, MD, MRCP, FRCPC - Interventional Cardiology|
- Epstein AE, et al. (2008). ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): Developed in Collaboration With the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Circulation, 117(21): e350–e408. [Correction in Circulation, 120(5): e34–e35.]
- Hunt SA, et al. (2009). 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation, 119(14): e391–e479.
- McAlister FA, et al. (2007). Cardiac resynchronization therapy for patients with left ventricular systolic dysfunction: A systematic review. JAMA, 297(22): 2502–2514.
- Tang ASL, et al. (2010). Cardiac-resynchronization therapy for mild-to-moderate heart failure. New England Journal of Medicine, 363(25): 2385–2395.
- Van Rees JB, et al. (2011). Implantation-related complications of implantable cardioverter-defibrillators and cardiac resynchronization therapy devices. Journal of the American College of Cardiology, 58(10): 995–1000.
- Akoum NW, et al. (2008). Pacemaker therapy. In EG Nabel, ed., ACP Medicine, section 1, chap. 7. Hamilton, ON: BC Decker.
- McKelvie R (2011). Heart failure, search date August 2010. BMJ Clinical Evidence. Available online: http://www.clinicalevidence.com.
Last Updated:September 12, 2012