Arrhythmia Device Follow-up 101

I have been encouraged to share the meager knowledge I have of arrhythmia devices for those who may be interested. A brief background of my involvement in these devices: I trained in Diagnostic Cardiovascular technology both on the electrophysiologic and imaging level. I began my arrhythmia device training (moving forward I will use the industry accepted acronym CRM - Cardiac Rhythm Management) at a university hospital in downtown Toronto back in early 2003. I currently run a pacemaker clinic at a different Toronto hospital. I wrote two exams, both the Canadian CRM specialty exam in 2006 and the IBHRE (International) exam in 2007. My posts will tend to run on the side of generality, but I hope even veterans in the industry may glean some benefit from this and future posts on the subject. I do not endeavor to insult any one's intelligence, nor is this an instructional post per say. I merely wish to share my experiences to either the benefit or amusement of my fellow cohorts. So, enough about me and on with the show so to speak.

It may sound a tad hokey but the greatest tool (usually) you have in your arsenal for following and troubleshooting CRM's is definitely your patient. Unless the patient is clearly a veterinary historian or otherwise inclined to vague and non-specific symptom relation, they are your best jumping off point. I can illustrate this with a very good example I recently encountered. A patient of mine, Mr. P, came to clinic for his annual check up. His original implant indication was sick sinus syndrome and for the past 5 years has had a total pacing percentage of no more than <0.1%.>30 bpm. He indeed after 5 years of almost no pacing, became fully pacemaker dependent. This is not an unusual occurrence as ~15-25% of SSS patients will develop varying degrees of AV block.
Mr. P was programmed to a rate responsive mode with a conservative rate response curve and performed a hall walk. In comparison with his marked shortness of breath walking 20 feet from the waiting room to the clinic versus the hallwalk totalling 60 feet, he was totally relieved of his symptoms with the new parameters.
I was quite lucky to have such a diligent and observant patient to aid me in programming his appropriately. More often than not, you will be met with stoicism or vague reporting of symptoms and parameters will by and large become trial and error.
The take home message here is listening to your patients can make your job easier.