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MINERVA: Managed atrial, ventricular pacing benefited patients with bradycardia
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DALLAS — In patients with bradycardia and atrial tachyarrhythmias, atrial preventive pacing and atrial antitachycardia pacing plus managed ventricular pacing was linked to a lower rate of adverse outcomes compared with standard dual-chamber pacing.
Managing both ventricular and atrial pacing had a particularly strong effect on reducing risk for permanent AF, Giuseppe Boriani, MD, PhD, of the University of Bologna, Italy, said at a press conference.
Researchers for the MINERVA trial enrolled 1,166 patients (mean age, 74 years) with bradycardia and previous atrial tachyarrhythmias, but no history of AF or third-degree atrioventricular block. They investigated whether pacing only when rhythm disturbances occur would lead to better outcomes in patients with bradycardia as compared with continuous pacing, as well as the benefits of managing ventricular pacing only and managing both ventricular and atrial pacing.
Patients were assigned to one of three arms: a control group that received standard dual-chamber pacing; an intervention group that received atrial preventive pacing and atrial antitachycardia pacing plus managed ventricular pacing; or and an intervention group that received managed ventricular pacing.
Managed ventricular, atrial pacing beneficial
The primary endpoint was a composite of death, CV hospitalizations and permanent AF at 2 years. It occurred in 19.8% of the group that received managed ventricular and atrial pacing vs. 26.5% of controls (HR=0.74; 95% CI, 0.55-0.99), and in 21.9% of the group that received managed ventricular pacing (HR vs. controls=0.89; 95% CI 0.77-1.03).
Managed atrial pacing plus managed ventricular pacing was associated with reduced risk for permanent AF (HR vs. controls=0.39; 95% CI, 95% CI, 0.21-0.75). The effect was not significant in patients who received only managed ventricular pacing. This led the researchers to conclude that improvement in the primary outcome for patients who received managed atrial pacing and managed ventricular pacing was primarily related to a decrease in the progression of atrial tachyarrhythmias to permanent AF, Boriani said.
“The biggest difference was found in permanent AF, where there was a 61% reduction of risk for the later stage of AF, when the arrhythmia becomes untreatable,” he said at the press conference. “This means that for every 20 patients treated with [devices that can manage ventricular pacing and atrial pacing], we save one evolution to permanent AF.”
Theories validated
MINERVA is the culmination of years of research in which researchers gradually learned that managing both atrial and ventricular pacing, particularly limiting right ventricular pacing, could have benefits in patients with bradycardia, said invited discussant Anthony Tang, MD, of Western University, London, Ontario, Canada.
“We now understand that when you increase ventricular pacing, pacing in the right ventricle is not beneficial and in fact may increase AF,” he said. “Atrial pacing may prevent AF, but … pacing in the right ventricle might increase AF; therefore, the two may cancel one another. We thought that by combining increased atrial pacing and reduced ventricular pacing, the combination would be beneficial, and this is indeed what this particular study utilized and was able to demonstrate.” – by Erik Swain
For more information:
Boriani G. LBCT.03. Medical and surgical approaches to heart failure outcomes. Presented at: the American Heart Association Scientific Sessions; Nov. 16-20, 2013; Dallas.
Disclosure: Boriani reports no relevant financial disclosures.
Perspective
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Mark A. Creager, MD, FACC
This trial moves the electrophysiology field forward. It was a novel approach in programming pacemakers that was creative and well-reasoned, and addressed an issue that is very familiar to those in the cardiac community who deal with patients who have pacemakers for bradycardia who also have atrial tachyarrhythmias. It was a positive finding and increases our understanding of why these patients develop AF when they’re being paced, and it demonstrates a way that we might be able to prevent that. The impact was impressive. There was a significant reduction in the rate of permanent AF and many of its consequences.
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