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Dual-chamber pacemaker may be best for certain patients
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In a joint consensus statement issued by the Heart Rhythm Society and the American College of Cardiology Foundation, experts urged physicians to consider the use of dual-chamber pacemakers instead of single-chamber pacemakers in patients with sinus node dysfunction or atrioventricular block.
The statement, published in the Journal of the American College of Cardiology and HeartRhythm, builds on guidelines developed in 2008 by the HRS, the American Heart Association and the ACCF, which did not contain specific recommendations regarding selection of pacemaker mode or device.
“This document should be used as a supplement to the published 2008 guidelines document, functioning as a guide to facilitate the selection of single- vs. dual-chamber devices for patients who already meet guidelines for pacemaker implantation,” the consensus group wrote, adding that these recommendations only apply to situations in which the decision to proceed with pacemaker implantation has been made.
Recommendations
After reviewing data from four studies — the Danish study, the Pacemaker Selection in the Elderly (PASE) study, the Canadian Trial of Physiologic Pacing (CTOPP) and the Mode Selection Trial (MOST) — the consensus group recommends using atrial or dual-chamber pacing in patients with sinus node dysfunction to decrease the risk for atrial fibrillation, stroke and pacemaker syndrome, and improve quality of life.
Patients with atrioventricular block are also likely to benefit from dual-chamber pacing, according to the statement. Although comparable with ventricular pacing in terms of CV outcomes, such as stroke, mortality, HF and AF, dual-chamber pacing may reduce the risk for pacemaker syndrome and improve some quality-of-life measures, the consensus group wrote. This conclusion was based on data from PASE, CTOPP and United Kingdom Pacing and Cardiovascular Events (UKPACE).
The statement also addresses the appropriateness of dual-chamber vs. single-chamber devices in several less common indications for a pacemaker. Members of the consensus group said dual-chamber pacing may be beneficial for patients with hypersensitive carotid sinus syndrome and neurocardiogenic syncope, but they recommend against single-chamber atrial pacing in both conditions. Similarly, they concluded that dual-chamber devices maybe useful for patients with medically refractory, symptomatic hypertrophic cardiomyopathy and recommend against single-chamber pacing in this patient population. However, these recommendations are based on small clinical studies, and “it is unlikely that large randomized trials will ever be conducted in these unique clinical subgroups.”
Other considerations
The consensus group examined additional factors that may influence pacemaker selection, including costs and complications.
Cost-effectiveness appeared to vary widely among dual-chamber devices, according to members of the consensus group, leading them to conclude that “it should not be the dominant factor determining pacing device mode and selection.”
Studies also showed higher overall complication rates with dual-chamber pacing as compared with single-chamber ventricular pacing systems. Nevertheless, the consensus group concluded: “While implant complications are more frequent for dual-chamber than single-chamber pacemakers, the higher risk of complications for dual-chamber pacemakers is offset over time by the need to reoperate on a number of patients with single-chamber pacemakers for [atrioventricular] block or pacemaker syndrome.”
For more information:
Gillis AM. J Am Coll Cardiol. 2012;doi:10.1016/j.jacc.2012.06.011.
Perspective
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Andrew Epstein, MD
This consensus statement on pacemaker device and mode selection is a “one-stop shop” for physicians who are interested in and implant pacemakers and defibrillators. As clearly stated in bold type [in the statement], the document addresses choices that need to be addressed only when the clinical decision for pacing has already been made. In one place, the statement provides a balanced and incredibly comprehensive review of the data on device and mode selection. The following are three key points of discussion. First, implantation of a dual-chamber pacing (DDD) device is appropriate for patients with sinus rhythm and intact atrioventricular conduction. This is important since the National Coverage Determination (NCD) for pacing, which determines appropriateness for Medicare billing, was last updated May 9, 1985 for dual-chamber pacing and allows it only when single-chamber pacing has lead to pacemaker syndrome or is expected to cause it, and for patients with HF! Furthermore, DDD as opposed to ventricular single-pacing (VVI), decreases the risk for AF, and dual-chamber devices allow for diagnosing asymptomatic AF with the possibility that treatment can be provided to prevent stroke. Second, the statement supports the use of VVI pacing for patients with atrioventricular block and sinus rhythm in special circumstances, such as for those with sedentary lifestyles or important comorbidities. Although this may surprise some, it has important implications for cost savings and demonstrating that the electrophysiology community is sensitive to the importance of cost-effectiveness. Third, the role of single-lead, atrioventricular pacing (VVD) using a single lead is revisited, which has the potential benefit of decreasing the burden of leads, especially in young people who have a lifetime dependence on hardware that has more limited longevity. The authors are to be commended.
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