Syncope in a patient with a pacemaker commands urgent action to ascertain its cause and provide appropriate treatment. This is a well accepted statement but the field has evolved in recent years and, strangely, has received little attention.
Many considerations bear on this issue. First, syncope in pacemaker patients is not common but may be more so than generally considered. The lack of frequency may be attributed to better technology and greater expertise amongst practitioners but it should be modulated by the fact that more patients today receive pacemakers for other indications than syncope, rendering them unlikely to sustain syncope even if their pacemaker system fails. Second, we now live in an era of telemedicine where remote monitoring not only provides an opportunity to identify technological or arrhythmic causes of syncope in a pacemaker patient but also a chance for the patient very readily to report such an episode to hospital carers.1 Third, more patients today receive pacemakers for reflex syncope where the device is not expected to achieve the results in syncope prevention that pertain in atrioventricular block (AVB).2,3 Included with this aspect of syncope in pacemaker patients must also now be the realisation that syncope may be reflex in the largest group of patients worldwide that receive pacemakers, those with sino-atrial node disease.4
It is in these contexts that a review of this serious clinical problem is due.