Published online before print June 26, 2006, doi: 10.1161/CIRCULATIONAHA.105.610303
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(Circulation. 2006;114:11-17.)
© 2006 American Heart Association, Inc.
Arrhythmia/Electrophysiology |
Cardiovascular Outcomes With Atrial-Based Pacing Compared With Ventricular Pacing
Meta-Analysis of Randomized Trials, Using Individual Patient Data
From the Population Health Research Institute (J.S.H., S.Y., S.J.C.), McMaster University, Hamilton, Canada; the Department of Cardiovascular Sciences (W.D.T., J.D.S.), University of Leicester, England; Mount Sinai Medical Center (G.A.L.), Miami Beach, Fla; Aarhus University Hospital (H.R.A.), Skejby Sygehus, Denmark; University of Toronto (K.E.T.), Toronto, Canada; Medical College of Virginia (K.A.E.), Richmond; Duke University (K.L.L.), Durham, NC; Nottingham Clinical Research Group (A.M.S.), Nottingham, England; National Heart, Lung, and Blood Institute (E.B.S.), Bethesda, Md; University of California (L.G.), San Francisco; Henderson Research Centre (R.S.R.), McMaster University, Hamilton, Canada; and St. George’s University of London (A.J.C.), London, England.
Correspondence to Jeff Healey, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada, L8L 2X2. E-mail healeyj{at}hhsc.ca
Received December 29, 2005; revision received March 30, 2006; accepted April 24, 2006.
Background— Several randomized trials have compared atrial-based (dual-chamber or atrial) pacing with ventricular pacing in patients with bradycardia. No trial has shown a mortality reduction, and only 1 small trial suggested a reduction in stroke. The goal of this review was to determine whether atrial-based pacing prevents major cardiovascular events.
Methods and Results— A systematic review was performed of publications since 1980. For inclusion, trials had to compare an atrial-based with a ventricular-based pacing mode; use a randomized, controlled, parallel design; and have data on mortality, stroke, heart failure, or atrial fibrillation. Individual patient data were obtained from 5 of the 8 identified studies, representing 95% of patients in the 8 trials, and a total of 35 000 patient-years of follow-up. There was no significant heterogeneity among the results of the individual trials. There was no significant reduction in mortality (hazard ratio [HR], 0.95; 95% confidence interval [CI], 0.87 to 1.03; P=0.19) or heart failure (HR, 0.89; 95% CI, 0.77 to 1.03; P=0.15) with atrial-based pacing. There was a significant reduction in atrial fibrillation (HR, 0.80; 95% CI, 0.72 to 0.89; P=0.00003) and a reduction in stroke that was of borderline significance (HR, 0.81; 95% CI, 0.67 to 0.99; P=0.035). There was no convincing evidence that any patient subgroup received special benefit from atrial-based pacing.
Conclusions— Compared with ventricular pacing, the use of atrial-based pacing does not improve survival or reduce heart failure or cardiovascular death. However, atrial-based pacing reduces the incidence of atrial fibrillation and may modestly reduce stroke.
CLINICAL PERSPECTIVE
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