In GUCH News (issue 72), patient and member Kulsoom Akbar shared her story with us. Kulsoom, now aged 25, had her first pacemaker fitted at just 17 months. Growing up with the device, Kulsoom has encountered many issues, but has also embraced the life that the pacemaker has allowed her to enjoy. Here, we explore some of the day-to-day issues that people with pacemakers might need to consider. Adult Congenital Heart Specialist Nurses, Bethan Shiers, and Wendy Visser, both from the Bristol Heart Institute, provide us with the medical facts and advice regarding some of the common concerns about pacemakers.
Having a pacemaker can vastly improve a patient’s quality of life and can be life- saving. Modern pacemakers are very reliable and comfortable, and, weighing only 20-50 grams, they are smaller than your average matchbox.
Most pacemakers are fitted just under the collar bone and will have one or more leads which are passed into the heart via a vein. The pacemaker has a pulse generator – the pacemaker box, a battery powered electrical circuit, and one or more electrode leads.
The type of pacemaker fitted will depend on the specific condition.
Why a pacemaker?
A pacemaker may be required if a patient has a condition which causes disruption to the heart’s natural pacemaker.
The pacemaker will take over from the heart’s natural pacemaker. Some send out electrical impulses all the time, whilst others just activate when needed.
Most pacemakers are fitted under local anaesthetic with a very mild sedative so that the patient feels relaxed. The procedure usually takes about an hour.
An incision is made under the left collarbone and the pacemaker box fitted between the skin and the chest muscle.
The patient may feel slightly uncomfortable but should not feel any pain. The incision is then stitched up and covered with a dressing.
A patient may be given antibiotics before and after the pacemaker is inserted to minimise the risk of infection. The wound should be kept clean and dry. Patients should avoid wearing tight clothing over the wound until it has healed and speak to their GP if there is any redness or swelling, which could indicate infection.
For the first six weeks after a pacemaker has been inserted, it’s advised not to lift the arm on the side of the pacemaker above the shoulder or behind the back. After a few weeks, extra tissue will grow around the lead which will prevent the lead(s) from moving out of place. The patient can then return to normal activity.
Strenuous activity should be avoided until after the first follow-up appointment; which is usually about six weeks after the pacemaker is fitted.
People with an ordinary driving licence can drive after one week, provided they have informed the DVLA that they have a pacemaker; have not experienced dizziness or fainting; attend check-ups; have not had a recent MRI or heart surgery and do not have any other conditions that would disqualify them from driving. Patients cannot drive Large Goods Vehicles or passenger- carrying vehicles for at least six weeks after a pacemaker is inserted. The DVLA may ask the patient’s cardiologist to provide details of the condition.
Everyday Life with a pacemaker
Clearing airport security tends to take longer for Kulsoom due to her pacemaker. She has found that this can be exacerbated by some countries not understanding what a pacemaker is. Despite carrying a Pacemaker Identification Card, Kulsoom comments that, in her experience, not all security staff know what they are looking for or what to do, making the experience more frustrating and anxiety-ridden.
She recalls an occasion when she was about 15. Security staff tried to insist that she go through the security system. Her father challenged this and ended up arguing with the security staff, reducing Kulsoom to tears. She also recalls being asked to show her pacemaker scar to security staff. As she has become older Kulsoom has become more philosophical, commenting “It’s always been a pain to go to airports. I used to get annoyed but now I just enjoy the experience”.
Airport systems rarely cause problems with pacemakers. However, as the metal detector can detect a pacemaker, patients are advised to tell the security staff that they have a pacemaker and request that a hand-held scanning device is used. Patients should carry their Pacemaker Identification Card, issued by their pacemaker department. It may be useful to carry a letter, if possible translated into the language of the country being visited. The Foreign and Commonwealth Office might be able to offer advice regarding specific destinations. If the patient walks briskly through the security system, without lingering, it cannot damage the pacemaker. The same applies to shops and libraries that use security equipment.
Other possible sources of interference with pacemaker function:
Kulsoom remembers using the luggage exit on the London Underground as a child, having been told that she could not use the ticket barrier due to her pacemaker. It is not known whether ticket barriers will affect a pacemaker. In adults, the barrier would usually be below the height of the pacemaker. Patients can safely use mobile telephones but are advised to hold them to the ear on the opposite side to the pacemaker, keep them more than 15 centimetres (6 inches) away from the pacemaker, and not to put them in a pocket over the pacemaker. Bluetooth headsets do not appear to interfere with pacemakers.
Using electrical household equipment and appliances, such as microwaves, televisions, radios, electric blankets and gardening machinery will not affect a pacemaker.
Most MP3 headphones contain a magnetic substance which can cause interference if they are used too close to a pacemaker. Patients are advised to keep the headphones at least 3 centimetres (1.2 inches) away
from the pacemaker and not to place the headphones in a breast pocket or draped over the chest. Care should be taken not to rest your head on the chest of someone with a pacemaker whilst wearing headphones.
Arc welding equipment could interfere with the operation of the pacemaker. Some workplaces have strong electromagnetic fields which can interfere with the pacemaker. The pacemaker clinic may be able to advise further.
Some hospital equipment may interfere with pacemakers. Patients should avoid Magnetic Resonance Imaging (MRI) machines. Some electrical nerve and muscle stimulations (TENS units) may interfere with a pacemaker, depending on where they are applied. If any of these treatments are suggested, patients are advised to seek advice from their pacemaker clinic.
After the first outpatient appointment, most sports and activities can be carried out. Patients should discuss any contact sport with their pacemaker clinic as collisions could damage the pacemaker. Pacemaker patients should not lift heavy weights or shoot rifles, due to the kick back. Despite leading an active life, and recently climbing the mountain Arthur’s Seat in Edinburgh, Kulsoom finds that strenuous activities can cause her scars to hurt.
Kulsoom’s parents were cautious about allowing her to go on theme park rides. When she was eighteen, she decided that this was now her decision, so asked her consultant. He confirmed that her parents concerns were largely unfounded and only certain rides, not all, were not appropriate for her as they use magnets. Although she would love to go on all rides, Kulsoom is happy that she can go on all the other rides and now loves visiting theme parks, having previously hated it due to her frustration at only being allowed to go on the mini-rides.
Kulsoom’s earliest memories are of the frequent visits to London for check-ups.
Pacemaker checks are not invasive or painful. Modern pacemakers can store information about the state of the battery.
It was at one of her routine check-ups that Kulsoom learned that the battery in her pacemaker needed to be replaced although she was unaware of any problems. It is therefore important to have regular checks at the pacemaker clinic. The appointment will depend on the type of pacemaker and how
well it is working. Checks will be performed on the pacemaker settings and the battery life. The technician will apply three or four electrodes to the chest. A special magnet will be placed over the pacemaker on the chest. The computer then “talks” to the pacemaker. The technician can adjust the settings on the pacemaker using the magnet and computer.
Generally patients do not feel anything during the check. The technician may ask the patient questions to see how they are getting on. The check-up can take up to 30 to 40 minutes, depending on how complicated the particular pacemaker is.
Although some precautions and restrictions are necessary for pacemaker users, these are minimal and should not interfere with normal day-to-day life and activities too much. Patients can therefore enjoy life knowing that their heart rhythm is being looked after by their device.
Your pacemaker team, Cardiac Liaison Nurse or pacemaker department are best placed to provide specific advice on the type of pacemaker that you have and the precautions that you will need to take.
A booklet about pacemakers and the precautions that patients should take can be downloaded from The British Heart Foundation website at www.bhf.org.uk — Pacemakers
With thanks to Kulsoom Akbar, and to Cardiac Nurse Specialists Bethan Shiers and Wendy Visser, Bristol Heart Institute.
This article was first printed in Issue 73 of GUCH News – Summer 2013