Objective: To present three illustrative cases of PD-associated autonomic dysregulation with severe orthostatic symptoms in which cardiac pacing strategies were associated with substantial clinical improvement.

Background: Cardiovascular autonomic failure is a common non-motor feature of Parkinson’s disease (PD) and frequently manifests as neurogenic orthostatic hypotension (nOH). Management currently encompasses non-pharmacological and pharmacological therapies; these however often facilitate only insufficient symptom control or mediate adverse effects. Moreover, therapeutic options remain limited in patients with concomitant chronotropic incompetence or bradyarrhythmia. Evidence regarding the role of cardiac pacing in this context is scarce.

Method: Case Series

Case 1 describes a PD patient with recurrent, severe orthostatic syncope in the setting of sick sinus syndrome with chronotropic incompetence. A dual-chamber pacemaker was implanted. Post-implantation autonomic testing continued to demonstrate marked orthostatic blood pressure drops; however, from the time of implantation onward, the patient remained clinically free of syncope.

Cases 2 and 3 involve PD patients with pre-existing dual-chamber pacemakers (implanted for sick sinus syndrome and third-degree atrioventricular block, respectively) who presented with pronounced orthostatic intolerance despite optimized conservative and pharmacological treatment. In both patients, an increase in the programmed lower rate limit (from 50 to 60 bpm and from 60 to 80 bpm, respectively) led to a marked reduction in orthostatic symptoms and improved functional capacity.

Results: Across all three cases, augmentation of baseline heart rate—either by de novo implantation or device reprogramming—was associated with sustained symptomatic relief, despite persistent objective evidence of orthostatic dysregulation.

Conclusion: These cases highlight the potential contribution of impaired chronotropic response to symptomatic orthostatic intolerance in PD. Cardiac pacing may represent a complementary therapeutic option in carefully selected patients with combined autonomic failure and bradyarrhythmia. This report does not aim to advocate routine pacemaker implantation in PD patients with nOH but rather to share clinical experience in an area where data beyond established non-pharmacological and pharmacological strategies remain sparse.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/cardiac-pacing-strategies-for-cardiovascular-autonomic-dysfunction-in-parkinsons-disease/