What is it about?

Many people with permanent pacemakers are older and have clinical features that also increase the risk of heart failure with preserved ejection fraction, known as HFpEF. However, HFpEF can be difficult to recognise in this population because symptoms such as breathlessness, fatigue and reduced exercise capacity may be subtle, non-specific or attributed to ageing, comorbidities or the pacemaker itself. The PM-HFpEF study was designed to determine the prevalence and clinical profile of HFpEF in a contemporary population of patients with conventional pacemakers. To achieve this, the study uses a structured ESC-based screening pathway combining clinical assessment, natriuretic peptide testing, electrocardiography, echocardiography, pacemaker interrogation, frailty assessment and quality-of-life evaluation. In selected patients, exercise diastolic stress echocardiography is used to clarify borderline findings. By applying a systematic screening approach, the study aims to improve the recognition and characterisation of HFpEF in an under-studied group of patients.

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Why is it important?

HFpEF is increasingly common in older adults and is associated with symptoms, hospitalisations and reduced quality of life. Patients with permanent pacemakers are particularly relevant for HFpEF screening because they frequently present with age-related cardiovascular risk factors, atrial arrhythmias, renal dysfunction and hypertension. In addition, long-term ventricular pacing may contribute to haemodynamic changes and pacing-related syndromes that can overlap with, or complicate the recognition of, heart failure symptoms. Despite regular follow-up in pacemaker clinics, heart failure assessment is often not performed through a standardised pathway. As a result, clinically relevant HFpEF may remain unrecognised, especially when symptoms overlap with ageing, frailty, comorbidities or pacing-related complaints. This study is important because it applies a structured, ESC-based screening approach to determine the prevalence and clinical profile of HFpEF in a contemporary pacemaker population. By integrating device follow-up with broader cardiovascular assessment, it may help clinicians identify patients who require further evaluation, closer monitoring or targeted heart failure management.

Perspectives

This article is closely connected to my daily clinical work. In pacemaker follow-up clinics, we often meet older patients who are regularly monitored from a device perspective, but whose symptoms can be much harder to interpret. Breathlessness, fatigue or reduced exercise capacity may be attributed to ageing, frailty, comorbidities or even to the pacemaker itself, while heart failure with preserved ejection fraction may remain under-recognised. For me, this study grew from that clinical gap. It reflects the idea that a pacemaker check should not always end with confirming that the device is working well. In selected patients, it can also be an opportunity to look more broadly at symptoms, cardiac function and quality of life. I hope this protocol encourages a more integrated approach to pacemaker patients, bringing together device follow-up and heart failure screening in a practical and reproducible way.

ELIZABETH DOS SANTOS
Local Health Unit of Gaia and Espinho

Read the Original

This page is a summary of: Screening for HFpEF in pacemaker patients: Study design and protocol of the PM-HFpEF study, PLOS One, June 2026, PLOS,
DOI: 10.1371/journal.pone.0349667.
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