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 American Journal of  Medical Science
 and Innovation (AJMSI)

How Long Can One Live Without a Permanent Pacemaker in Complete Heart Block? A 
Case Report from Rural Kenya  

Onyango C. Vonwicks1*, Auma Nicholas2, Malalu P. Collins1, Fryda C. William1

Volume 4 Issue 1, Year 2025
ISSN: 2836-8509 (Online)

DOI: https://doi.org/10.54536/ajmsi.v4i1.4385
https://journals.e-palli.com/home/index.php/ajmsi

Article Information ABSTRACT

Received: January 10, 2025

Accepted: February 12, 2025

Published: March 11, 2025

Complete heart block is characterized by a total atrioventricular dissociation resulting in 
junctional or ventricular escape rhythms. It is associated with high cardiovascular mortality 
rates without definitive treatment. The current guidelines recommend the placement of  
a permanent pacemaker to manage all cases of  a complete heart block not caused by 
reversible or physiological causes, irrespective of  patient symptoms. The natural history and 
prognosis of  complete heart block not treated with pacemaker placement are unknown. In 
this study, we present the case of  an elderly woman from rural Kenya who was diagnosed 
with a complete heart block 30 years ago and recommended a permanent pacemaker but 
declined. She has lived a relatively normal and active life without a pacemaker, albeit with 
compensated heart failure. This case suggests that a subset of  patients with complete heart 
block may have good clinical outcomes without the need for a permanent pacemaker. It 
would be worthwhile to do further studies to map this subset of  patients’ natural history 
and prognostic factors. 

Keywords

Case Report, Complete Heart 
Block, Kenya, Permanent 
Pacemaker, Third-Degree 
Atrioventricular Block

1 Department of  Medicine, St. Joseph Rift Valley Hospital, Gilgil, Nakuru County, Kenya
2 Department of  Endoscopy, St. Joseph Rift Valley Hospital, Gilgil, Nakuru County, Kenya
* Corresponding author’s e-mail: drvonczelo@gmail.com

INTRODUCTION
A complete heart block (CHB) (also called third-
degree atrioventricular block) occurs when there is no 
conduction at all from the atria to the ventricles and may 
be paroxysmal or permanent (Kusumoto et al., 2019). 
The causes may be reversible or irreversible, including 
myocardial infarction, myocarditis, infective endocarditis, 
cardiomyopathy, hyperkalemia, atrioventricular nodal 
blocking medications (e.g., beta-blockers, calcium channel 
blockers, digoxin, adenosine, etc.), post-cardiac surgery/
procedures, congenital heart block, idiopathic, etc. (Meloy 
et al., 2022). Patients may present with fatigue, chest 
pain, dyspnea, palpitations, presyncope and syncope, 
heart failure, cardiogenic shock, or sudden cardiac arrest 
(Meloy et al., 2022). They have bradycardia due to the 
occurrence of  escape rhythms, which may be junctional 
(rates of  40-60 bpm) or ventricular (rates of  20-40 bpm). 
Patients with CHB have very poor outcomes without 
prompt and appropriate treatment with pacemaker 
placement (Knabben et al., 2025). CHB is an independent 
predictor of  in-patient and 6-year mortality (Savic et al., 
2021). The prevalence of  CHB varies widely based on 
various populations, e.g., 0.004% in China to 0.04% in 
Iceland and Michigan (Kojic et al., 1999; Ostrander et al., 
1965; Shan et al., 2021). The diagnosis is confirmed on 
an electrocardiogram, which shows severe bradycardia 
and evidence of  atrioventricular dissociation: the atrial 
(P waves) and ventricular (QRS complexes) activities are 
independent of  each other. The atrial rate is higher than 
the junctional or ventricular escape rate. See Figures 1 and 
2 below by Yang et al. (2018) and Bhasin and Roy (2019), 
respectively. Electrophysiology (EP) study may rarely be 
used to make the diagnosis.

Figure 1: The EKG shows a complete heart block with 
a junctional escape rhythm, an atrial rate of  around 90 
bpm, and a ventricular rate of  45 bpm (Yang et al., 2018).

Figure 2: The EKG shows a complete heart block with 
a ventricular escape rhythm, an atrial rate of  about 88 
bpm, and a ventricular rate of  about 30 bpm (Bhasin & 
Roy, 2019).



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The management guidelines for CHB have been 
proposed by the European Society for Cardiology, the 
American College of  Cardiology, the American Heart 
Association, and the Heart Rhythm Society (Glikson et 
al., 2021; Kusumoto et al., 2019). In summary, patients 
with complete heart block not caused by physiologic or 
reversible causes should undergo a permanent pacemaker 
placement irrespective of  the symptoms (class I 
recommendation with level C evidence). The long-term 
outcomes of  CHB are not well documented, probably 
because they are usually treated with pacemakers in 
urgent-care settings (Knabben et al., 2025). The prognosis 
is most likely influenced by the underlying etiology of  the 
CHB (reversible vs. irreversible causes), the severity of  the 
clinical presentation, and the occurrence of  hemodynamic 
instability (this can lead to death if  not promptly treated 
by temporary and/or permanent pacemaker placement) 
(Knabben et al., 2025). 

Case Summary
Clinical history and physical examination
A 79-year-old widow, a mother of  10 and a farmer from 
Mbaruk, Nakuru County, Kenya, first presented to us 
in 2021 with clinically decompensated biventricular 
congestive heart failure and severe bradycardia (heart 
rate of  34 bpm) on a background of  poorly controlled 
isolated systolic hypertension, which was diagnosed 
some 30 years prior (baseline home BPs of  163-
170/71-73 mmHg during this presentation.). She had 
been non-compliant on the prescribed amlodipine-
losartan-hydrochlorothiazide combination tablet. She 
was overweight (BMI of  28.8 kg/M2) but with no other 
cardiovascular risk factors. She had been diagnosed with 
hypertension and a “slow heart” in a peripheral facility in 
1995 and was put on unknown medications and referred 
to a cardiologist for a possible pacemaker placement. 
She defaulted on the medications and did not go for her 
referral. She continued to have “occasional” dizziness 
thereafter with her heart rates ranging from 30 to 40 bpm 
whenever they were checked. In the year 2008, she had 
several syncopal episodes and was referred to the national 
referral hospital, where she was diagnosed with “severe 
hypertension” and a complete heart block. Six months 
before this, her husband had died, and her home and 
property had been destroyed in the 2007-2008 Kenyan 
post-election violence. Subsequent multiple cardiologist 
reviews and recommendations for a permanent 
pacemaker placement were futile as she declined “the 
placement of  any gadgets in me that God did not put 
in there Himself!” She underwent serial counseling for 
the same, but she declined. She describes herself  as 
a “staunch Christian with unshakable faith in God.” 
Reportedly, the etiology of  the CHB was never found 
despite “multiple blood tests,” and it was thus labeled 
idiopathic. No invasive tests or procedures were done 
during the etiological workup. She subsequently defaulted 
on her discharge medications (unknown) and was not 
on any treatment until 2 years before her presentation 

to us, when she was put on an antihypertensive and 
referred to a cardiologist, who again failed to talk her 
into getting a pacemaker upon re-confirming a complete 
heart block. Interestingly, she reported no further pre-
syncopal or syncopal episodes after 2008 except for on-
off  palpitations with heavy physical exertions. She had 
no history suggesting heart failure or acute coronary 
syndrome before her presentation to us. 
Presently, she was in decompensated biventricular heart 
failure at New York Heart Association (NYHA) dyspnea 
scale grade 3 precipitated by a community-acquired 
pneumonia (CURB-65 score of  2). Her BP was 163/79 
mmHg, pulse rate of  32 bpm (which did not change 
following a trial administration of  1.2 mg of  atropine 
intravenously), with an oxygen saturation of  97% in 
room air. She was afebrile. She had grade 3 bi-pedal 
pitting edema, elevated JVP with the classical cannon ‘a’ 
wave, a hyperactive precordium with variable but normal 
S1, S2, and an S3 gallop rhythm and no murmurs, bi-
basal crackles on the lung auscultation with right mid-
lung zone crepitations, and a tipped tender hepatomegaly 
on abdominal examination. The rest of  the physical 
examination was unremarkable. 

Work-up, Management, and Follow-up
Her baseline laboratory tests were all normal, including 
a complete blood count, renal, thyroid, and liver panels, 
serum electrolytes including calcium, blood sugar, lipid 
profile, and a urinalysis. Serum troponins were negative. 
The COVID-19 antigen and PCR tests were negative. Her 
EKG showed a complete heart block with a ventricular 
escape rate of  36 bpm, some premature ventricular 
contractions, and no evidence of  acute ischemic changes. 
See Figure 3 below. Her CXR showed cardiomegaly with 
pulmonary edema and right lung mid-lobe opacification. 
An interval echocardiogram showed grade 2 diastolic 
dysfunction, dilated left atrium and ventricle with a left 
ventricular ejection fraction of  87%, no regional wall 
motion anomalies, normal valves, no thrombus, and no 
pericardial effusion. Another echocardiogram done 12 
months later showed a small apical thrombus.

Figure 3: The EKG done in 2021 shows a complete 
heart block with ventricular escape rhythm; the atrial rate 
is about 90 bpm, while the ventricular rate is about 36 
bpm. Two premature ventricular contractions are noted.



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Figure 4: The EKG done in 2024 shows a complete 
heart block with ventricular escape rhythm; the atrial rate 
is about 84 bpm, while the ventricular rate is about 30 
bpm.

We successfully managed her as an outpatient with 
furosemide, spironolactone, losartan, an antibiotic (co-
amoxiclav), and supportive therapy. We added rivaroxaban 
later on following the finding of  an apical thrombus. We 
counseled her several times on the need for a pacemaker, 
but she has declined. It is now 4 years since she has 
been on follow-up at our clinic and 30 years since she 
was diagnosed with a complete heart block. She remains 
in complete heart block (see figure 4 below) and in 
compensated heart failure (NYHA 1-2, current baseline), 
but with no pacemaker. She has had no admissions for 
heart failure, no chest pains, no syncope, but occasional 
mild dizziness while working on her farm. She had an 
episode of  orthostatic hypotension in 2023 following 
an acute diarrheal illness, which resolved with careful 
hydration and temporary withdrawal of  the diuretics. She 
still does almost all activities of  daily living independently.

Discussion
Patients with CHB who are managed with a permanent 
pacemaker have an overall good prognosis. Alpert and 
Katti demonstrated overall survival rates of  91% at 1 
year, 63% at 5 years and 41% at 10 years (Alpert & Katti, 
1982). This is influenced by patient demographics and 
the underlying cause and/or complications of  the CHB, 
e.g., advanced age, congestive heart failure, ischemic heart 
disease, etc., which were associated with lower survival 
rates compared to the presence of  hypertension, diabetes, 
or valvular heart disease in this study (Alpert & Katti, 
1982).
Little information is recorded in the literature about the 
prognosis of  patients with CHB who are not treated with 
a pacemaker. A ten-year retrospective study by Edhag 
and Swahn of  101 patients with arrhythmic syncope and 
CHB not treated with pacemakers (68 of  them had CHB) 
showed that of  those who had CHB, survival was 68% 
at 1 year and 37% at 5 years (Edhag & Swahn, 1976). 
There are several case reports of  patients who were 
diagnosed with CHB and managed without a permanent 
pacemaker placement who led relatively active lives. For 
example, a 23-year-old Chinese woman diagnosed with 

congenital CHB at the onset of  an episode of  Adams-
Stokes attack declined a pacemaker and led an active 
life during a 28-year follow-up period in which she had 
an uneventful pregnancy (Su et al., 2022). A 26-year-old 
primigravida with CHB remained stable throughout the 
pregnancy and underwent a cesarean section under spinal 
anesthesia without a pacemaker (Swain et al., 2022). Our 
patient has seemingly followed a clinical course almost 
similar to the Chinese woman (although the latter had an 
initial temporary pacemaker and later on had a relatively 
good compensation for her CHB from the junctional 
escape rhythm). Our patient was diagnosed with CHB 
during an Adams-Stokes attack and recommended for 
a permanent pacemaker placement but declined due to 
personal and religious reasons. She has lived for about 
30 years now with CHB without a pacemaker and has 
been active throughout, including in her old age presently, 
where she is still doing most of  her activities of  daily 
living independently. She has survived several episodes 
of  presyncope and syncopal attacks and has been in 
compensated heart failure with preserved ejection 
fraction since we started following her 4 years ago. The 
reasons for her relatively stable clinical course remain 
largely speculative for now, including the possible roles 
of  unknown cardiovascular compensatory mechanisms 
and her religious faith. We are unable to do any further 
etiological and prognostic studies for her CHB (e.g., 
cardiac MRI, biopsy, etc.). Undoubtedly, more studies 
are needed to correctly map out the natural history of  
CHB and elicit more reliable and predictable prognostic 
markers in this subset of  patients who decline permanent 
pacemaker placement but seemingly remain relatively 
stable over many years.

CONCLUSION
The case of  our patient adds to a subset of  known (and 
unknown) patients with CHB who surprisingly led a 
relatively stable and active clinical course over many years 
without any pacemaker placement. This may suggest that 
some patients with CHB may not necessarily require a 
permanent pacemaker, as is the current evidence-based 
recommendation by various guidelines. Accordingly, more 
studies are needed to map out the natural history of  CHB 
in this subset of  patients and to determine more reliable 
markers of  prognosis to influence decisions regarding 
true indications and timing of  pacemaker placement.

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