CLINICAL TRIALS OF PACING MODE SELECTION

doi:10.1016/S0733-8651(05)70124-7

Cardiology Clinics

Volume 18, Issue 1, 1 February 2000, Pages 1-23

https://doi.org/10.1016/S0733-8651(05)70124-7 Get rights and content

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DUAL-CHAMBER VERSUS VENTRICULAR PACING

Since Zoll's¹¹⁵ report in 1952 of the first clinical application of cardiac pacing in the management of bradycardia, sinus node dysfunction and atrioventricular (AV) conduction disorders have remained the major indications for permanent pacemaker implantation in the United States¹² and other parts of the world.38, 47, 75 Dual-chamber pacing has the theoretical advantage over single-chamber ventricular pacing in that it resembles normal cardiac physiology by maintaining synchrony of atrial and

CURRENT RECOMMENDATIONS

Largely based on nonrandomized observational data and expert opinions, statements in favor of dual-chamber pacing were made in guidelines published by the British Pacing and Electrophysiology Group (a specialist subgroup of the British Cardiac Society)²⁰ and jointly by the American Heart Association (AHA) and the American College of Cardiology (ACC).²⁶ The rate of dual-chamber pacemaker implantation, however, has remained lower than recommended in most countries: This low rate has been

SMALL CROSSOVER STUDIES

In an appraisal of current data on dual-chamber versus ventricular pacing,²¹ the authors (S. J. C., C. R. K.) summarized the results of many small crossover trials assessing the effect of pacing mode on effort tolerance (Table 1) and quality of life (Table 2). These studies suggest that dual-chamber pacing improves effort tolerance when compared with fixed-rate ventricular pacing but not with rate-adaptive ventricular pacing. The poorer performance with fixed-rate ventricular pacing was

Earlier Studies

In a subsequent review on survival in patients with pacemakers,¹⁰ the authors (S. J. C., C. R. K.) alluded to the conflicting retrospective data in the literature regarding pacing mode and survival benefits in patients paced for AV block: The findings of Alpert et al² in 180 patients and Linde-Edelstam et al⁵⁸ in 148 patients suggested probable survival benefits with physiologic pacing only in patients with congestive heart failure, whereas overall total mortality was similar in the two patient

PROSPECTIVE RANDOMIZED STUDIES

Three small-scale randomized, controlled studies on the effect of pacing mode selection on clinical outcome, survival, or quality of life have been reported (Table 6).

ONGOING CLINICAL TRIALS

Seven well-recognized but as yet unpublished randomized, controlled trials assess the effects of pacing mode selection on clinical outcomes, survival, or quality of life. Four studies have been completed, although not yet fully reported, and the other three are still in progress. These studies are summarized in Tables 7 and 8.

OTHER PACING TRIALS

As stated in the introductory section, clinical bradycardia from sick sinus syndrome or AV conduction disease has been the major indication for permanent pacemaker implantation worldwide.12, 38, 47, 75 Observational studies and prospective trials on pacing have been performed mainly on these patient populations. The discussion on pacemaker trials in this article has focused on the conventional comparison between physiologic (single-chamber atrial or dual-chamber) and nonphysiologic

CONCLUSIONS

Nonrandomized observational data appear to lend support to the theoretic advantage of physiologic pacing over nonphysiologic ventricular pacing in terms of major clinical outcomes and survival benefits. These studies are weak methodologically, however. The first prospective randomized, controlled trial on pacing mode selection, the Danish Study, was a relatively small-scale study on 225 elderly patients with sick sinus syndrome.⁸ After the initial 3.3 years of follow-up, ventricular pacing was

ACKNOWLEDGMENTS

We thank Dr. Anzhen Qi, of the Division of Cardiology, St. Paul's Hospital, Vancouver, for her assistance in the preparation of some of the tables and figures in this article.

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: Address reprint requests to Chuen Y. Tang, MBBS, Minneapolis Heart Institute, Abbott Northwestern Hospital, 920 East 28th Street, Suite 300, Minneapolis, MN 55407, e-mail: [email protected]

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