Every heartbeat is a testament to the body’s resilience, yet for millions, that rhythm may falter as they age, putting their lives at risk. For elderly patients, the idea of surgery, especially for something as vital as installing a pacemaker, can be scary due to the possible risks and the physical toll. However, pacemakers — small devices implanted to help regulate the heart’s rhythm — have transformed cardiac care, offering patients a longer life by preventing slow heart rates. While it’s true that surgery can be particularly challenging for elderly patients, the life-enhancing benefits of pacemakers far outweighs the potential consequences of going through this procedure. 

Pacemakers are important devices that help treat bradyarrhythmia, a heart rate beating fewer than 60 beats per minute, which can be due to family history, medication side effects, heart defects, and heart attacks. “All cardiac pacemakers are generally composed of a pulse generator that generates the electrical current required for stimulation of heart musculature and 1 or 2 electrodes, which are responsible for transmitting the electrical activity generated by the pulse generator to the heart musculature” (Lak, 2022). The pacemaker essentially sends an electrical current replicating the one a normal heart is supposed to have. It sends the current through these electrodes whenever the heart falls below a certain beats per minute that could be dangerous to the patient. The electrical current gives the heart a shock and allows it to return back to a normal, safer rhythm.  

Living with a pacemaker does require adjustments to daily life. For example, patients must avoid electromagnetic interference by maintaining a safe distance from certain items, such as airport security scanners, MRIs, electric drills, and cell phones (Richard N. Fogoros, 2024). These changes can significantly impact an elderly patient’s day-to-day activities, requiring additional care and awareness. Richard Fogoros’ article, 14 Things You Can’t Do With a Pacemaker, outlines some of these challenges and the necessary lifestyle modifications. While these adjustments might seem restrictive, they are minor compared to the benefits pacemakers provide in improving heart function and extending life. 

The benefits of pacemakers are clear in survival data. “The observed 5-year survival was 45% in our patients aged 85 years or more. It compares well with previous studies on patients > 80 years that showed a survival in the range between 40% and 49%” (Marini et al. 2019). For instance, nearly 90% of 50-year old patients who receive pacemakers can extend their lifespan by 10 years. These findings emphasize the importance of timely intervention, even for elderly patients. Extending life by even a few years can provide precious time for individuals to enjoy with loved ones and pursue meaningful experiences. 

Figure 1: A graph showing survival of patients based on age group after pacemaker implantation (Trabosky et al. 2023)

According to Trabosky et al., the later you implant pacemakers the decreased probability of survival as the years go by. In the figure above you can clearly see that when the pacemaker is implanted into a 50 year old, almost 90 percent have their lifespan increased by 10 years. As the age you implant the pacemaker increases the positive impact on the lifespan of the patient decreases. In patients that are 70 years old less than 50 percent have their lifespan increased by 10 years. The graph clearly shows the later you receive the pacemaker the less it will add to your lifespan. This figure shows just how much of an impact pacemakers can make. An elderly patient that is 65 and above can have their lifespan increased by even a couple years is an amazing feat. It means they can have more time to spend with their significant others, their kids, and their grandchildren. Even the extra year a pacemaker can provide is vital to allowing a person to live out their life to the fullest. 

However, opposing sides argue that even with the increased lifespan that pacemakers may provide, how long does it actually take elderly patients to recover from surgery? Older patients will have a longer recovery time than a younger patient and are expected to have more complications. Elderly surgery patients will require more support than a younger one, from both professional healthcare providers and other individuals (Whitlock). For elderly patients the path to recovery becomes much different after a surgery. They require more oversight and may even need to be put into a rehabilitation facility to receive proper care. Due to their age, they have increased chances of complications which can increase recovery time even longer. These unknown variables make it an even scarier experience for the elderly. The increased lifespan that pacemakers can provide just becomes used to recover from the surgery and not actually be able to enjoy your life to the fullest. 

Furthermore, Kenneth Covinsky’s research on the cognitive, functional, and psychological effects of surgery raises valid concerns. Overall, 17 percent of the patients who underwent major surgery died within a year. This led to increased mortality, including activities of daily living, inability to walk several blocks, dementia and depression (Covinsky, 2024). These factors highlight the potential risks and the need for a balanced approach when deciding whether surgery is the right choice for elderly patients. The association between increased mortality and difficulties with activities of daily living, mobility limitations, dementia, and depression suggests that these vulnerabilities may compromise a patient’s ability to recover from the physical and psychological stress of surgery. 

With so many possible side effects, researchers are trying to look for non surgical methods to help cure bradyarrhythmia. The article “Harnessing cell reprogramming for Adrian biological pacing” by Chih-Min Lin M.D., director of the division of cardiology at Taipei General Hospital, talks about the potential of biological pacemakers as a natural alternative to conventional electronic pacemakers. Current electronic pacemakers are effective but have many risks such as mechanical failure, infection, and a lack of adaptability. The authors advocate for cell programming as a solution where normal cells are converted into pacemaker cardiomyocytes. These cells mimic the body’s intrinsic rhythm, and they are a more organic reliability solution because you are using the person’s own ordinary cells. This article talks about an alternative to electrical pacemakers that could be safer, reduce reliance on implantation hardware, and reduce the surgery’s needed.

Figure 2: Development of pacemaker implantation (Liu et al. 2023)

The figure above from the article “Harnessing cell reprogramming for Adrian biological pacing” by Chih-Min Liu, shows the progression of pacemakers throughout time. But the fourth image is the alternative method that these researchers hope will become the new norm. It’s a clear diagram of the heart and shows the placement of the catheter which will place the biological product into the heart and allow the creation of a biological pacemaker. 

Pacemaker implantation in elderly patients presents a complex ethical problem that requires careful consideration of several key principles. Foremost among these is patient autonomy—the right of individuals to make informed decisions about their own healthcare. Ensuring that elderly patients fully understand the benefits, risks, and potential outcomes of pacemaker surgery is essential for honoring this autonomy. This involves transparent communication about the procedure’s impact on quality of life, possible complications, and the realistic expectations for recovery and longevity. Additionally, healthcare providers must provide an explanation of the potential benefits of pacemaker implantation against the risks and burdens it may impose. For some elderly patients, especially those with other illnesses or limited life expectancy, the invasiveness of surgery and the recovery period may outweigh the advantages of the device. Therefore, a thorough, individualized assessment is crucial to determine whether the intervention aligns with the patient’s overall health goals and values.

Furthermore, the decision-making process should involve a multidisciplinary approach, incorporating insights from cardiologists, geriatricians, ethicists, and, importantly, the patients and their families. This collaborative strategy ensures that all aspects of the patient’s health—physical, cognitive, and emotional—are considered. It also facilitates discussions about alternative treatments, including less invasive options or palliative care, when appropriate. By engaging in shared decision-making, healthcare providers can respect the patient’s autonomy while also fulfilling their ethical obligation to act in the patient’s best interest. Ultimately, the goal is to arrive at a decision that reflects the patient’s preferences and values, ensuring that the chosen course of action promotes their well-being and dignity.

This new innovative research highlights a different approach to treating bradyarrhythmia in a non surgical way. Patients could just come in and have a catheter that will turn a person’s normal cells into tiny pacemakers. It would be non invasive, no recovery time needed, and would provide the same benefits that pacemakers already provide just with less risk. More research is definitely needed, but this showcases how there is so much more to be done within medicine. So many areas where we can improve outcomes and the general quality of life for our patients. 

As future doctors we must be aware of the needs of our patients and the treatments that are best for them. Many of our future patients will be elderly and that completely changes the way we approach them in terms of treatment plans. We must be able to put ourselves in their shoes. Do they have the support they need to be able to properly recover after surgery? Do they have a support system at home? Are there alternative uncommon methods to help them? We must be able to think outside of the box and be aware of new treatments for our patients. This new alternative nonsurgical method being developed to treat bradyarrhythmia will be so helpful to the elderly. It will decrease recovery time and potential risks of treatment. 

Pacemakers have already revolutionized the treatment of bradyarrhythmia, and their impact on cardiac care continues to grow. Despite the challenges of surgery and recovery, their ability to extend life and improve heart function makes them an invaluable option for many elderly patients. There are still improvements to be made that can remove the recovery time of surgery. Alternatives like biological pacemakers promise to further enhance care, ensuring that patients can live longer, healthier lives with minimal disruption to their daily routines. This progress underscores the endless possibilities within medicine to improve outcomes and quality of life for all patients.