USRE37454E1 - Cardiac pacemaker with hystersis behavior - Google Patents

Abstract

A pacemaker having a hysteresis feature which permits intrinsic heart activity, controlled by the sinus node to resume optimally after pacing. The pacemaker has a programmable lower rate and upper rate, a programmable lower hysteresis rate (LRH) corresponding to a lower rate hysteresis interval (LRHI), and a programmable rate (IR) intermediate an upper pacing rate (UR) and a lower pacing rate (LR). A microprocessor measures the average rate of change MAVG in the intervals between consecutive ventricular depolarizations, and compares the last intrinsic escape interval RRN to the lower rate hysteresis interval (LRHI).If the last intrinsic escape interval RRN is longer than the lower rate hysteresis interval (LRHI), and if the value of MAVG is greater than a first preselected value SL1 but less than a second preselected value SL2, the pacemaker stimulates at the lower rate hysteresis (LRH) and thereafter gradually increases the pacing rate up to the intermediate rate (IR). A time counter maintains a continuous pacing at the intermediate rate (IR) for a predefined period of time, and the pacing rate is gradually decreased toward the lower pacing rate (LR).

Description

BACKGROUND OF THE INVENTION

The present invention relates to cardiac pacemakers, and more specifically to a pacemaker having a selectable hysteresis feature which compensates for sinus node malfunction.

It is well known that natural heart activity, including the depolarization of the sinus node provides optimum hemodynamic performance. Atrial or ventricular stimulations induced by such devices as cardiac pacemakers, generally delay or inhibit natural heart activity by preventing the depolarization of the sinus node.

The hysteresis feature was developed to address this concern, by allowing the pacemaker to follow the sensed sinus node depolarization to a certain predetermined rate below the programmed lower rate of the pacemaker. As such, the escape interval in conventional demand pacemakers equipped with hysteresis feature, is longer than the lower rate interval, for enabling the patient's intrinsic rhythm to control the heart as long as the intrinsic rate is maintained above a predetermined minimum rate. However, in selected patients, these conventional pacemakers do not generally allow the natural heart activity to resume normally after pacing.

The following patents provide a brief historical background for the development and use of the hysteresis feature as it relates to cardiac pacing technology. U.S. Pat. No. 4,856,523, entitled “RATE-RESPONSIVE PACEMAKER WITH AUTOMATIC MODE SWITCHING AND/OR VARIABLE HYSTERESIS RATE,” issued to Sholder et al, on Aug. 15, 1989, describes the inclusion of the hysteresis feature in a rate-responsive pacemaker, in an attempt to prevent competition between the pacemaker and the heart's SA node, when the anterograde conduction path is restored. The Sholder patent proposes to vary the hysteresis rate as a function of the pacemaker sensor rate, to a predetermined level upon sensing of the natural heart contraction during the escape interval, as illustrated in FIG. 3B and 4.

U.S. Pat. No. 4,363,325 entitled “MODE ADAPTIVE PACER,” issued to Roline et al, on Dec. 14, 1982, and assigned to Medtronic, Inc., discloses a multiple-mode pacer which automatically switches from an atrial synchronous mode to a ventricular inhibited mode when the intrinsic atrial rate drops below a preset hysteresis rate. The Roline patent is incorporated herein by reference.

While the above cited patents and other publications and studies relating to the hysteresis feature have attempted with varying degrees of success to allow the patient's intrinsic rhythm to control, none was completely successful in causing the natural heart activity to resume optimally after pacing.

SUMMARY OF THE INVENTION

Briefly, the above and further objects and features of the present invention are realized by providing a new and improved pacemaker having a hysteresis feature which permits intrinsic heart activity, controlled by the sinus node to resume optimally after pacing.

The pacemaker has a programmable lower rate and upper rate, a programmable lower hysteresis rate (LRH) corresponding to a lower rate hysteresis interval (LRHI), and a programmable rate (IR) intermediate an upper pacing rate (UR) and a lower pacing rate (LR). A microprocessor measures the average rate of change in the intervals between consecutive ventricular depolarizations M_AVG, and compares the last intrinsic escape (RR_N) interval to the lower rate hysteresis interval (LRHI).

If the last intrinsic ventricular interval(RR_N) will be longer than the lower rate hysteresis interval (LRHI), and if the value of M_AVGis greater than a first preselected value SL₁but less than a second preselected value SL₂, the pacemaker stimulates at the lower rate hysteresis (LRH) and thereafter gradually increases the pacing rate up to the intermediate rate (IR) while the pulse generator is in the demand mode. A time counter maintains a continuous pacing at the intermediate rate (IR) for a predefined period of time, and the pacing rate is gradually decreased down to the lower pacing rate (LR).

The accompanying Table I summarizes the features offered by the present invention, and correlates these features to FIGS. 2A through 6.

TABLE 1
FIG. 2A	FIG. 2B	FIG. 3	FIG. 4	FIG. 5	FIG. 6
(Step)	(Step)	(Region)	(Curve)	(Curve)	(Curve)
220,		I	KL
222
220,		VI	LPQ
224
	226,	III	K′L
	228,
	232
	226,	IV	LPQ
	228,
	230
	226,	II		AB	AB
	234,
	236
	226,	V		BCDEF	BB′CDE′R
	234,
	238-254

BRIEF DESCRIPTION OF THE DRAWINGS

The above and other options, features and advantages of the present invention will be more apparent from the following more particular description thereof, presented in conjunction with accompanying drawings, wherein:

FIG. 1 is a block diagram showing the primary functional blocks of the pacemaker according to the present invention;

FIGS. 2A and 2B are flow charts of a simplified software program suitable for use in the pacemaker of FIG. 1;

FIG. 3 is an illustration of two exemplary generally increasing limit functions SL₁and SL₂which determine the behavior of the pacemaker according to the software program of FIGS. 2A and 2B;

FIG. 4 is a response curve illustrating the variation of the pacing rate according to the present invention;

FIG. 5 is another response curve illustrating pacing rate variation according to the present invention; and

FIG. 6 is yet another response curve illustrating pacing rate variation according to the present invention.

DESCRIPTION OF THE PREFERRED EMBODIMENT

Referring now to the drawings and more particularly to FIG. 1 thereof, there is illustrated a block diagram of the components of thepacemaker100 of the present invention.Block150 illustrates a microprocessor chip, such as the CDP1802 microprocessor made by RCA. Themicroprocessor150 is connected to aROM memory151 and to aRAM memory152 via adata bus156. Anaddress bus154 interconnects theROM memory151, theRAM memory152, and acontroller circuit158. Thecontroller circuit158, in turn, controls apacer circuit161 and apacemaker output stage160 for stimulating the heart. Thepacemaker100 could be used for single chamber or dual chamber pacing.

FIGS. 2A and 2B together illustrate the flow diagram of a program200 which is stored in theROM memory151, and which is run once each cycle in thepacemaker100. Alternatively, the program200 could be stored in theRAM memory152. The program200 does not contain all the steps which are carried out by themicroprocessor150, but it includes those steps that illustrate the operation of thepacemaker100 according to the present invention. Several variables of the software-controlled operations can be reprogrammed through theRAM memory152.

Before proceeding with a more detailed explanation of the present invention, it would be helpful to review the following definitions:

“Intrinsic rhythm” or “intrinsic rate” of the heart is the rate at which the heart naturally beats on its own, without being stimulated by a pacemaker-provided stimulus.

“Hysteresis” means extension of the range of rates at which inhibition of the pacemaker pulses will occur. The base pacing interval is increased by the hysteresis interval. Thus, hysteresis provides a longer escape interval, thereby giving the heart an opportunity to beat on its own before the pacer provides stimulation pulses.

“Pacing Rate” is the rate at which the stimulation pulses are provided from the heart from the pacemaker.

Starting atstep201, the program200 is initiated, and the intrinsic ventricular depolarizations are sensed at202. While the program200 uses ventricular events for carrying out the invention, it should be understood that atrial events can alternatively be used.

The program200 measures, atstep204, the intrinsic escape interval, such as the RR interval between two successive sensed ventricular events, and calculates, atstep206, a parameter “D”, as follows:

D=RR_i-RR_i-1,   (1)

where RR_iis the RR interval which has been recently measured atstep204; and RR_i-1is the RR interval preceding RR_i. It therefore follows that the parameter D is indicative of the rate of change of the RR interval.

In this respect, if D were found to have a positive value, it is an indication that the RR interval is increasing with time, and consequently the intrinsic rate of the heart is dropping. The reverse holds true where D has a negative value, indicating that the RR interval is decreasing and that the intrinsic rate is increasing. Additionally, the absolute value of D represents the rate of change of the intervals of the intrinsic ventricular depolarizations, which is also illustrated by the slope the curve AB in FIGS. 5 and 6, as it will be described later in greater detail.

If atstep208 the value of D is found to be negative, this value will not be used since it represents an increase in the intrinsic ventricular depolarization rate, and the above subroutine, includingsteps202,204,206 andstep208, is repeated until a positive value of D is found. The dashedline207 indicates that if the value of D is found to be negative, then the attending physician will have the option to either cause the software to set n=0, atstep203, or to restart atstep202. The preferred embodiment of the present invention relates principally to precipitous drops in heart rates, and consequently only positive values of D are added and stored at212 by the randomaccess memory RAM152.

While the preferred embodiment includes adding only those positive values of D, it will become apparent to those skilled in the art that consecutive D values could alternatively be added. The feature of selecting between consecutive and positive D values is a programmable feature, and is selectable by the attending physician.

In order to detect and ascertain the occurrence of precipitous heart rate drops, the software200 calculates the average rate of increase M_AVGof a preselected number “N” of RR intervals. Preferably, M_AVGis calculated over a predetermined period of time “T”. If during that period T, the value of M_AVGis less than a first limit function SL₁, then this is an indication that the intrinsic heart rate has not dropped rapidly enough to warrant the use of corrective measures, such as the activation of the hysteresis feature. If on the other hand, the value of M_AVGreaches or exceeds the first limit SL₁, but is less than a second limit SL₂, the pacemaker is instructed to take appropriate measures, as will be described later in greater detail.

To achieve this function, the program200 stores the calculated positive values of D, atstep212, and counts the number of events “n” indicative of a positive D value. When the count reaches a preprogrammed number “N” of stored beats or reaches the time period T, the program200 calculates the sum “M” of the N stored values D, as follows:$\begin{array}{cc}M=\sum _{j=1}^ND_j,& \left(2\right)\end{array}$

where j is an integer that varies between 1 and N; and where N is the number of stored beats.

The value of M is then averaged atstep217 over the number of stored beats N, as follows:$\begin{array}{cc}{M}_{\mathrm{AVG}}=\frac{M}{N}& \left(3\right)\end{array}$

In the preferred mode of the present invention the above parameters are assigned the following values:

N=6 beats.

T=15 seconds. It should, however, be understood that different values or ranges of values can alternatively be employed within the scope of the invention.

Digressing from the flow chart of FIG. 2A, and turning to FIG. 3, there is a shown lower limit function SL₁and an upper limit function SL₂which are identified by the numeral references10 and12, and which divide the quadrant into six regions: I, II, III, IV, V and VI. Each one of these regions will now be described in greater detail in relation to FIGS. 2A through 5. The horizontal coordinate axis represents time “t”, and the vertical coordinate axis represents RR intervals “RRI”.

As used in this specification, the LRI and LRHI parameters in the following context:

“LRI” means the Lower Rate Interval which corresponds to the lower pacing rate “LR” of the pacemaker, where LRI in milliseconds equals 60,000 divided by LR in beats per minute. LR is typically programmed to 70 beats per minute.

“LRHI” means the Lower Rate Hysteresis Interval that corresponds to the lower rate hysteresis “LRH” which is typically programmed to 50 beats per minute. LRHI in milliseconds equals 60,000 divided by LRH in beats per minute.

By comparing the average rate of change M_AVGto the programmable limit functions SL₁and SL₂, it would be possible to identify the region which corresponds to the mode of operation of thepacemaker100. SL₁and SL₂are boundaries between regions defining distinctly different operation of thepacemaker100. For clarity purposes, the six regions are defined as follows:

“Region I” is the portion of the quadrant defined by the lower limit function SL₁and by the RRI and time axes. Thepacemaker100 operates in Region I whenever the value of M_AVGis less than SL₁; and the last intrinsic ventricular escape interval RR_Nis shorter than the lower rate hysteresis interval LRHI. Pacing is inhibited in Region I, as illustrated by the curve KL in FIG. 4, and bystep222 of FIG.2A. The curve KL shows the heart rate decreasing at a slow rate.

“Region II” is the portion of the quadrant defined by the limit functions SL₁and SL₂, and by the lower rate hysteresis interval LRHI axis. Thepacemaker100 operates in Region II whenever the value of M_AVGis greater than SL₁, but less than SL₂; and the last intrinsic ventricular escape interval RR_Nis shorter than LRHI. Pacing is inhibited in Region II, as illustrated by the curve AB in FIGS. 5 and 6, and by step236 of FIG.2B. The curve AB shows the heart rate decreasing at an intermediate rate.

“Region III” is the portion of the quadrant defined by the upper limit function SL₂, by the LRI axis and by the lower rate hysteresis interval LRHI axis. Thepacemaker100 operates in Region III whenever the value of M_AVGis greater than SL₂; and the last intrinsic escape interval RR_Nis shorter than LRHI. Pacing is inhibited in Region III, as illustrated by the curve K′L in FIG. 4, and by thestep232 of FIG.2B. The curve K′L shows the heart rate decreasing precipitously, as opposed to curve KL, which represents a more modest heart rate drop in Region I.

“Region IV” is the portion of the quadrant above the lower rate hysteresis interval LRHI axis, and defined by the RRI axis and by the upper limit function SL₂. Thepacemaker100 operates in Region IV whenever the value of M_AVGis greater than SL₂; and the last intrinsic escape interval RR_Nwill be longer than LRHI. As illustrated by the curve LPQ in FIG. 4, and by thestep230 of FIG. 2B, pacing is carried out at the lower rate LR. It should however be understood that pacing could be alternatively carried out at the lower rate hysteresis LRH.

“Region V” will be the portion of the quadrant above the lower rate hysteresis interval LRHI axis, between the two limit functions SL₁and SL₂. Thepacemaker100 operates in Region V whenever the value of M_AVGis less than SL₂but greater than SL₁, and the last intrinsic escape interval RR_Nis longer than LRHI. As illustrated by the curves BCDEF and BB′CDE′R in FIGS. 5 and 6 respectively, and bysteps238 through254 of FIG. 2B, pacing starts at the lower rate hysteresis rate LRH and gradually increases until the pacing rate reaches an intermediate pacing rate IR. Pacing at IR is maintained for a predetermined period of time, and is thereafter gradually reduced until it reaches the lower rate LR. Pacing is maintained at the lower rate until the intrinsic rate exceeds the pacemaker lower rate, as illustrated by the curve FG in FIG.5. The pacemaker operation in Region V is triggered by an intermediate rate of decrease in the intrinsic hear rate.

“Region VI” is the portion of the quadrant defined by the lower limit function and by the lower limit function SL₁. Thepacemaker100 operates in Region VI whenever the value of M_AVGis less than SL₁; and the last intrinsic ventricular escape interval RR_Nwill be longer than the lower rate hysteresis interval LRHI. As illustrated by the curve LPQ in FIG. 4, and by thestep224 of FIG. 2A, pacing is carried out at the lower rate LR. It should however be understood that pacing could be alternatively carried out at the lower rate hysteresis LRH.

Returning now to FIG. 2A, the program200 compares M_AVGto SL₁andstep218. If M_AVGis less than SL₁, then a further determination is made atstep220 whether the last ventricular intrinsic escape interval RR_Nis less than or equal to LRHI. If it is, thepacemaker100 operates in Region I, and pacing is inhibited, as indicated bystep222 in FIG.2A and by the response curve KL in FIG.4.

If the intrinsic escape interval (RR_N) is determined atstep220, to be equal to or tend to exceed LRHI, and if there is no sensed event at a shorter interval, while the pacemaker is still in the demand mode, thepacemaker100 will operate in Region IV, and stimulation is carried out at the lower pacing rate LR, as illustrated by the curve LPQ in FIG.4. The curves in FIGS. 4,5 and6 which are drawn in dashed lines indicate that pacing is inhibited, while the curves drawn in solid lines indicate that pacing is occurring.

Returning now to step218 in the flow chart of FIG. 2A, if the program200 determines that M_AVGis greater than or equal to SL₁then a further determination is made atstep226 whether M_AVGis less than or equal to SL₂. If M_AVGis found to be greater than SL₂then thepacemaker100 will operate in either Region III or Region IV. A further decision is made atstep228 whether the last intrinsic escape interval RR_Nis less than or equal to the lower rate hysteresis interval (LRHI).

If the program200 determines that RR_Nis less than or equal to LRHI then thepacemaker100 will operate in Region III, and as indicated bystep232 of FIG. 2B, and by the curve K′L in FIG. 4, pacing will be inhibited. If on the other hand, it is determined atstep228, that RR_Nis greater than LRHI, then thepacemaker100 will operate in Region IV and as indicated bystep230 of FIG. 2B, and by the curve LPQ in FIG. 4, pacing is carried out at the lower pacing rate (LR).

Thepacemaker100 identifies and reacts to intermediate drops in the intrinsic heart rate, whenever M_AVGis found to be intermediate the limit functions SL₁and SL₂, as follows:

SL₁≦M_AVG≦SL₂  (4)

In the above condition, the pacemaker is caused to pace at a gradually increasing pacing rate until it reaches a predetermined intermediate pacing rate (IR) which is lower than, or in certain circumstances, equal to, the upper pacing rate (UR). Demand pacing is maintained at the intermediate pacing rate (IR) for a predetermined period of time, and is thereafter reduced gradually.

With reference to FIG. 2B, the program200 determines atstep234 whether the last intrinsic escape interval RR_Nis less than or equal to LRHI. If it is, then thepacemaker100 will operate in Region II, and as indicated by step236, and by the curve AB in FIGS. 5 and 6, pacing is inhibited.

If however, it is determined atstep234 that RR_Nwill tend to be longer than LRHI, then the condition set forth in equation (6) above is satisfied, and thepacemaker100 will operate in Region V, and will respond by pacing at the lower rate hysteresis (LRH) for a predetermined period of time or a preset number of beats, as illustrated by the dashed line BB′ in FIG. 6, and bystep238 in FIG.2B.

It should however be understood that thepacemaker100 could alternatively bypassstep238 and start pacing along curve BC (FIG.5), with one paced beat at the lower rate hysteresis (LRH). In this respect, pacing is started at point B (FIG. 5) and the pacing rate is incrementally increased until it reaches the intermediate rate (IR). The intermediate rate IR is programmable, and could be changed by the attending physician. The incremental increase in the pacing rate is illustrated by the curves BC in FIGS. 5 and 6. During this period, thepacemaker100 is in the inhibited mode for single chamber pacemakers, or in the DDD or fully automated mode for dual chamber pacemakers.

The incremental increase of the pacing rate is achieved bysteps240 through244, whereby the value of the pacing rate is incrementally increased by a center increment value X (step240), and a determination is made atstep242 whether the pacing rate is less than or equal to IR. Once IR is reached, then, as indicated bystep244, a time counter is set to maintain the continuous pacing at that intermediate rate (IR) for a preselected programmable period of time, such as for five minutes. This continuous pacing at the intermediate rate is illustrated by curve CD in FIGS. 5 and 6. If during the execution of thesubroutine244 through248, an intrinsic rhythm is sensed at245, then the intrinsic rate prevails, and pacing is inhibited.

Once the counter time lapses, then, as illustrated by the curves DE and DE′ in FIG. 5 and 6 respectively, the pacing rate is gradually decreased from the intermediate pacing rate (IR), toward the lower pacing rate (LR). This decrement is achieved by the subroutine250-252, where the pacing rate is decreased by a counter decrement value Y until the pacing rate reaches the lower rate LR.

If decremental pacing is maintained until it reaches the lower rate LR, thepacemaker100 starts pacing at that lower rate, as illustrated by the curve EF in FIG. 5, and the routine200 is repeated. If an intrinsic rhythm is sensed at any time during the decremental change (curve DE′) in the pacing rate, then the intrinsic rate prevails, and pacing is inhibited, as illustrated by the curve E′RS in FIG.6. The subroutine200 is thereafter repeated.

It is therefore clear that the new approach described in the present invention teaches away from the conventional hysteresis response feature. In the present invention, whenever an intermediate drop in the heart rate occurs and the hysteresis feature is activated, the natural heart rate resumes and is tracked until it reaches the hysteresis rate. Thereafter, the pacing rate is increased until the intermediate rate (IR) is reached. Pacing at that intermediate rate is maintained for a predetermined period of time, and thereafter allowed to gradually decay toward the lower rate.

It should become apparent to those skilled in the art after reviewing the present description, that the present invention can be made an integral part of single chamber and dual chamber pacemakers which operate in one or more of the programmed modes: SSI, SSIR, DDD, DDDR, DVI, DVIR, DDI and/or DDIR. The present hysteresis feature can be applied to the atrial and/or ventricular channels of a dual chamber pacemaker.

While the following ranges reflect exemplary values of IR, LR, UR, LRH, SL₁and SL₂, it should be understood to those skilled in the art that other values and ranges can also be employed and/or programmed.

100 bpm≦UR≦150 bpm.

80 bpm≦IR≦100 bpm.

60 bpm≦LR≦80 bpm.

40 bpm≦LRH≦60 bpm.

2%≦SL₁≦10%.

5%≦SL₂≦20%.

4 beats≦N≦16 beats.

While particular embodiments of the present invention have been disclosed, it is to be understood that various different modifications are possible and are contemplated within the scope and spirit of the specification, drawings, abstract, and appended claims.

Claims (31)

What is claimed is:

1. In a pacemaker having a programmable lower rate and upper rate, a programmable lower rate hysteresis (LRH) corresponding to a lower rate hysteresis interval (LRHI), and a programmable intermediate pacing rate (IR) the improvement comprising:

A. means for measuring rate of change M_AVGof successive cardiac intrinsic escape intervals;

B. means for comparing M_AVGto a first predefined limit SL₁;

C. means for comparing the last intrinsic escape interval to the lower rate hysteresis interval (LRHI); and

D. means for stimulating a heart at the lower rate hysteresis (LRH) and for gradually incrementing a pacing rate until the pacing ratio reaches the intermediate pacing rate (IR) if the last intrinsic escape interval is longer than the lower rate hysteresis interval (LRHI) and if said M_AVGis greater than SL₁.

2. The pacemaker according to claim1 further comprising:

A. time counter means for maintaining continuous pacing at the intermediate rate (IR) for a predefined period of time; and

B. means for allowing gradual decay of the pacing rate after said selected period of time has lapsed.

3. The pacemaker according to claim2, wherein said selected programmable time is set equal to five minutes.

4. The pacemaker according to claim1, wherein said means for measuring the rate of change M_AVGcomprising:

A. means for measuring intervals between two successive ventricular depolarizations (RR intervals); and

B. means for averaging the rate of change M_AVGof said successive RR intervals.

5. The pacemaker according to claim4, wherein said means for averaging the rate of change of said RR intervals comprises:

A. means for calculating a difference D between two successive RR intervals;

B. means for comparing said difference D to a predetermined reference value;

C. means for storing those values of D which are greater than said reference value;

D. means for calculating a sum M of N stored values of D, wherein N is a predetermined positive integer; and

E. means for setting M_AVGequal to M/N.

6. The pacemaker according to claim5, wherein said means for averaging M_AVGcomprising means for averaging the values of D greater than said reference value over a predefined period of time.

7. The pacemaker according to claim6, wherein said reference value is zero, and wherein only positive values of D are stored and added.

8. The pacemaker according to claim5, wherein N is set equal to six beats.

9. The pacemaker according to claim4, further including means for comparing M_AVGto a second predetermined limit SL₂wherein SL₂has a value greater than that of SL₁.

10. The pacemaker according to claim9, wherein said means for stimulating gradually increments the pacing rate until the pacing rate reaches the intermediate pacing rate (IR), if the last intrinsic escape interval RR_Nis longer than LRHI, and if M_AVGis greater than or equal to SL₁but less than or equal to SL₂.

11. The pacemaker according to claim9, further comprising means for inhibiting stimulation if M_AVGis greater than SL₂, and if the RR_Ninterval is less than or equal to LRHI.

12. The pacemaker according to claim11, further comprising means for stimulating at the lower rate if M_AVGis greater than SL₂, and if the RRN interval will be longer than LRHI.

13. The pacemaker according to claim11, further comprising:

A. means for inhibiting stimulation if M_AVGis greater than SL₂, and if the RR_Ninterval is less than or equal to LRH; and

B. means for stimulating at the lower rate if M_AVGis greater than SL₂, and if the RR_Ninterval will be longer than LRHI.

14. The pacemaker according to claim4, further including means for inhibiting stimulation if M_AVGis less than SL₁, and if the last intrinsic escape interval RR_Nis less than or equal to LRHI.

15. The pacemaker according to claim14, further comprising means for stimulating at the lower rate if M_AVGis less than SL₁, and if the RR_Ninterval will be greater than LRHI.

16. A method for pacing with a pacemaker having a programmable lower rate and upper rate, a programmable lower hysteresis rate (LRH) corresponding to a lower rate hysteresis interval (LRHI), and a programmable intermediate pacing rate (IR), the pacing method comprising the steps of:

A. measuring a rate of change of M_AVGof successive intrinsic escape intervals;

B. comparing M_AVGto a first predetermined limit SL₁;

C. comparing a last intrinsic escape interval RR_Nto the lower rate hysteresis interval (LRHI); and

D. stimulating at the lower rate hysteresis (LRH) and gradually incrementing a pacing rate until it reaches the intermediate pacing rate (IR) if the RR_Ninterval will be longer than the lower rate hysteresis interval (LRHI) and if said M_AVGis greater than SL₁.

17. The pacing method according to claim16 further comprising the steps of:

A. maintaining continuous pacing at the intermediate rate (IR) for a predefined period of time; and

B. allowing gradual decay of the pacing rate after said selected period of time has lapsed.

18. The pacing method according to claim17, wherein, said step of measuring the rate of change M_AVGcomprises:

A. measuring intervals between two successive ventricular depolarizations (RR intervals); and

B. averaging the rate of change M_AVGof said successive RR intervals;

19. The pacing method according to claim18, wherein said step of averaging the rate of change of said RR intervals comprises:

A. calculating a difference D between two successive RR intervals;

B. comparing the difference D to a predetermined reference value;

C. storing those values of D which are greater than said reference value;

D. calculating a sum M of N stored values of D, wherein N is a predetermined positive integer; and

E. setting M_AVGequal to M/N.

20. The pacing method according to claim19, further comprising the step comparing M_AVGto a second predetermined limit SL₂, wherein SL₂has a value greater than that of SL₁.

21. The pacing method according to claim20, wherein said step of stimulating comprises gradually incrementing the pacing rate until it reaches the intermediate pacing rate (IR), if the RRN interval will be longer than LRHI, and if M_AVGis greater than or equal to SL₁but less than or equal to SL₂.

22. The pacing method according to claim18, further comprises:

A. the step of inhibiting stimulation if M_AVGis less than SL₁, and if the last sensed RR interval is less than or equal to LRHI;

B. the step of stimulating at the lower rate if M_AVGis less than SL₁, and if the RR_Ninterval will be longer than LRHI;

C. the step of inhibiting stimulation if M_AVGis greater than SL₂, and if the RR_Ninterval is less than or equal to LRHI; and

D. the step of stimulating at the lower rate if M_AVGis greater than SL₂, and if the RR_Ninterval will be longer than LRHI.

23. A cardiac pacemaker comprising:

means for sensing depolarizations,

means for controlling the timing and delivery of pacing pulses to a heart, means for measuring the rate of depolarization from said sensed depolarizations and means for comparing the current rate to a recent past average rate and from said determining the rate of decrease, and means responsive to said means for determining rate decrease for generating control signals to said control means for pacing at predetermined rates above a lower pacing rate if said rate of decrease exceeds predetermined amounts.

24. A method of pacing the heat including the steps:

1)sensing electrical depolarizations within a heart chamber,

2)making a determination based on sensed depolarizations in said chamber of the intrinsic heart rate,

3)comparing the current intrinsic heart rate with previously sensed intrinsic heart rate to determine whether a rapid drop in heart rate of a predetermined size has occurred,

4)on the discovery of a rapid drop in heart rate of said predetermined size, pacing at predetermined rates higher than a lower pacing rate.

25. A method according to claim22 further comprising after step4:

decreasing the pacing rate gradually until either an intrinsic rate is established above the lower rate or the lower rate is reached whereupon pacing continues at the lower rate.

26. The method as set forth in claim24 wherein if the activity sensor indicates a sensor rate that is higher than the lower rate, pacing at the sensor rate.

27. A cardiac pacemaker, as set forth in claim23 and further comprising means for decreasing the pacing rate gradually until either an intrinsic rate is established above the lower rate or the lower rate is reached whereupon pacing continues at the lower rate.

28. A cardiac pacemaker as set forth in claim27 further comprising means for pacing at an activity sensor rate if said activity sensor rate is higher than the lower.

29. A heart stimulator comprising:

pulse generator means for generating and emitting stimulation pulses to a heart at a rate;

detector means for sensing events in said heart, including spontaneous heartbeats; and

control means, connected to said pulse generator means and to said detector means, for controlling the emission of stimulation pulses by said pulse generator means for causing the emission of a stimulation pulse if a spontaneous heartbeat rate as sensed by said detector means drops below a defined lower rate within a predetermined period and for causing said pulse generator means, when said spontaneous heartbeat rate falls below said defined lower rate within said period, to emit said stimulation pulses at rates faster than said defined lower rate.

30. A heart stimulator as set forth in claim29 wherein after emitting said stimulation pulses at a rate faster than said lower rate, said control means subsequently slows the rate of emission of said stimulation pulses down to said defined lower rate.

31. A heart stimulator as in claim29 or30 wherein if a sensor rate is higher than said defined lower rate, said, said means for controlling the timing and delivery of pacing pulses paces at a rate indicated by said sensor rate.

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