To pace or not to pace? Clinical decision-making for older people with frailty and bradycardia is often challenging. For ambulatory, symptomatic patients a pacing strategy is clearly recommended, however, for those patients with severe frailty or limited mobility with an absence of clearcut symptoms, management strategies usually take a shared decision-making approach. How are clinicians expected to provide patients and carers with an objective picture of things to come in such an evidence-light space? The featured publication by Warraich et al., entitled “Outcomes of bradyarrhythmia device implantation: a single-centre retrospective cohort study”, from this issue at https://doi.org/10.5837/bjc.2026.052, is a call to arms to aid clinicians by providing some metrics around the likelihood of benefit. Bradycardia and bradyarrhythmias are common in older people reaching the end of their natural life, and patients, families and clinicians are reluctant to implant a pacemaker device when impact on quality of life is doubtful. This said, syncope can have devastating consequences, particularly hip fractures and head injuries, so there is a risk either way. Geriatricians are heavily invested in falls prevention, and the promotion of physical activity to improve health and wellbeing in the latter stages of life, so implantation is usually the preferred choice in the majority of cases, but where should we draw the line?
What does this study add to the debate?
Warraich et al. reviewed data from 700 consecutive adults who underwent de novo bradycardia implantation (2016–2021), with a primary outcome of 12-month all-cause mortality. First, it is notable that the mean age of implantation was 78 years old. Baseline characteristics showed 45% of patients had at least mild frailty (318/700, Rockwood clinical frailty score [CFS] 5–8), and on average three to four significant comorbidities.
Of those implanted, 12.4% were dead at one-year post-implantation. Unsurprisingly, frailty was a significant predictor of mortality (hazard ratio [HR] 2.05, 95% confidence interval [CI] 1.61 to 2.60), alongside inpatient implantation (HR 3.48, 95%CI 2.28 to 5.32, p<0.0001) and key comorbidities including valvular heart disease, heart failure, malignancy, chronic kidney disease and atrial fibrillation/flutter. It is important to highlight that over 80% of patients with a CFS of 5–8 were alive at one-year follow-up, presumably benefiting from pacemaker implantation, either directly through the prevention of syncope, or at least providing reassurance.
A crucial limitation of this study is the absence of data describing eligible patients where a conservative approach was taken for comparison. We also have no detail regarding quality of life or functional status for those patients included in the study – important metrics for an older population.
What does this mean for our practice?
As highlighted by the authors of this retrospective analysis, some key clinical considerations should be drawn from these findings. First, risk assessments for patients undergoing device implantation are critical. A variety of clinical risk scores exist in the literature for survival post-cardiac defibrillator implantation, usually for primary prevention in heart failure, e.g. MADIT trial-based Risk Stratification Score (MRSS),1 Seattle Heart Failure Risk Model (SHFM)2 and FADES (NYHA Functional class, Age, Diabetes, Ejection fraction, and history of Smoking).3 These clinical calculators are commonly used in practice to aid decision-making, however, interestingly, none include any metrics of frailty, instead relying on New York Heart Association (NYHA) class as a proxy of physical functioning. For brady-pacing in a non-heart failure context, there is little in the literature to aid objective risk stratification. The findings of this paper would suggest a basic combination of age, frailty status and comorbidities provide a reasonable starting point for risk stratification in clinical practice.
So what is stopping us? Embedding clinical frailty assessments into routine pre-procedure pathways for older patients eligible for a bradycardia pacing device seems like a sensible course of action. The CFS4,5 used in this paper is now common practice in most clinical environments, and requires very little training to perform. There are a wealth of resources available to aid providers and staff, and assessments may also trigger additional services to patients, particularly in the inpatient setting (see British Geriatrics Society frailty hub, https://www.bgs.org.uk/hubs/frailty-hub, for more detail). Providers also have the option of using frailty indices, such as the electronic frailty index (eFI), which is automatically calculated in primary care.6 For many trusts this is readily available on electronic health records at the point of referral, creating a ready-made triage system for providers. The key barrier in practice now, is not the feasibility of accessing frailty data, rather how to action them with available resources.
According to the 2025 National Institute for Cardiovascular Outcomes Research (NICOR) National Audit of Cardiac Rhythm Management (NACRM), there were 46,883 pacemaker procedures performed across England, Wales and Northern Ireland in 2024/2025.7 Best practice guidelines would advocate comprehensive geriatric assessment (CGA) by an interdisciplinary team for an older person identified as having frailty, where a significant procedure was proposed.8 Given the huge number of patients being put forward for pacemaker implantation, this is not feasible for most centres without creating unacceptable delays, therefore, alternative strategies need to be considered. This is often the step where problems arise in clinical practice. Cutting corners and embedding CFS into automated pathways, bypassing comprehensive and personalised assessment, sets a dangerous precedent. The CFS should never be the sole dictator of decision-making, rather it should act as a trigger to consider complexity and involvement of the interdisciplinary team. A good example of how this can work is established transcatheter aortic valve implantation (TAVI) pathways, where involvement of a geriatrician as part of the patient selection multi-disciplinary team is embedded into National Institute for Health and Care Excellence (NICE) guidelines.9 Pathways for pacemaker implantation could take a similar form, but given the large numbers of eligible patients, this will take time, resource and champions to the cause. This type of approach to care is the direction of travel, with frailty assessments already suggested to aid decision-making around single versus dual-chamber ventricular pacing in atrioventricular block.10 A greater understanding of the predictors of patient outcomes is an important starting point when considering investment in such a strategy for all older people with an indication for brady-pacing.
A call to arms for more research
We need more research in this area to make good decisions for our patients and plan our services. When is a conservative approach justified? Warraich et al. provide some key information regarding mortality, but we need more data on quality of life, functional outcomes and rates of complications related to syncope/falls. With new minimally invasive technologies on the horizon to monitor and treat arrhythmias, and ancillary functions on offer, such as remote monitoring, research needs to keep pace to avoid being made redundant. There is also a debate to be had around cost-effectiveness and sustainability, crucial to ensure research leads to meaningful change for patients and services on the ground.
Conflicts of interest
JKT has previously filled a research post funded by Medtronic, and received consultancy fees from Medtronic.
Funding
None.
Editors’ note
See also the article by Warraich et al. from this issue at https://doi.org/10.5837/bjc.2026.052.
References
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2. Bilchick KC, Wang Y, Cheng A et al. Seattle heart failure and proportional risk models predict benefit from implantable cardioverter-defibrillators. J Am Coll Cardiol 2017;69:2606–18. https://doi.org/10.1016/j.jacc.2017.03.568
3. van Rees JB, Borleffs CJW, van Welsenes GH et al. Clinical prediction model for death prior to appropriate therapy in primary prevention implantable cardioverter defibrillator patients with ischaemic heart disease: the FADES risk score. Heart 2012;98:872–7. https://doi.org/10.1136/heartjnl-2011-300632
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7. National Institute for Cardiovascular Outcomes Research. National Audit of Cardiac Rhythm Management (NACRM). Available at: https://www.nicor.org.uk/national-cardiac-audit-programme/cardiac-rhythm-audit-nacrm
8. Turner G, Clegg A. Best practice guidelines for the management of frailty: a British Geriatrics Society, Age UK and Royal College of General Practitioners report. Age Ageing 2014;43:744–7. https://doi.org/10.1093/ageing/afu138
9. National Institute for Health and Care Excellence. Transcatheter aortic valve implantation for aortic stenosis. HTG446. London: NICE, 2017. Available from: https://www.nice.org.uk/guidance/htg446
10. National Institute for Health and Care Excellence. Dual‑chamber pacemakers for symptomatic bradycardia due to sick sinus syndrome and/or atrioventricular block. TA88. London: NICE, 2014. Available from: https://www.nice.org.uk/guidance/ta88
