Effects of Physiologic Pacing versus Ventricular Pacing on the Risk of Stroke and Death Due to Cardiovascular Causes
Open accessAbstract
BACKGROUND: Evidence suggests that physiologic pacing (dual-chamber or atrial) may be superior to single-chamber (ventricular) pacing because it is associated with lower risks of atrial fibrillation, stroke, and death. These benefits have not been evaluated in a large, randomized, controlled trial. METHODS: At 32 Canadian centers, patients without chronic atrial fibrillation who were scheduled for a first implantation of a pacemaker to treat symptomatic bradycardia were eligible for enrollment. We randomly assigned patients to receive either a ventricular pacemaker or a physiologic pacemaker and followed them for an average of three years. The primary outcome was stroke or death due to cardiovascular causes. Secondary outcomes were death from any cause, atrial fibrillation, and hospitalization for heart failure. RESULTS: A total of 1474 patients were randomly assigned to receive a ventricular pacemaker and 1094 to receive a physiologic pacemaker. The annual rate of stroke or death due to cardiovascular causes was 5.5 percent with ventricular pacing, as compared with 4.9 percent with physiologic pacing (reduction in relative risk, 9.4 percent; 95 percent confidence interval, -10.5 to 25.7 percent [the negative value indicates an increase in risk]; P=0.33). The annual rate of atrial fibrillation was significantly lower among the patients in the physiologic-pacing group (5.3 percent) than among those in the ventricular-pacing group (6.6 percent), for a reduction in relative risk of 18.0 percent (95 percent confidence interval, 0.3 to 32.6 percent; P=0.05). The effect on the rate of atrial fibrillation was not apparent until two years after implantation. The observed annual rates of death from all causes and of hospitalization for heart failure were lower among the patients with a physiologic pacemaker than among those with a ventricular pacemaker, but not significantly so (annual rates of death, 6.6 percent with ventricular pacing and 6.3 percent with physiologic pacing; annual rates of hospitalization for heart failure, 3.5 percent and 3.1 percent, respectively). There were significantly more perioperative complications with physiologic pacing than with ventricular pacing (9.0 percent vs. 3.8 percent, P<0.001). CONCLUSIONS: Physiologic pacing provides little benefit over ventricular pacing for the prevention of stroke or death due to cardiovascular causes.
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In selected patients with sick sinus syndrome and fast ventricular response during AF paroxysms requiring rate control therapy, the addition of a pacemaker optimizes rate control and may help to control rhythm.
“In selected patients with sick sinus syndrome and fast ventricular response during AF paroxysms requiring rate control therapy, the addition of a pacemaker not only optimizes rate control but may also help to control rhythm.711,712”
From 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS (2016) · cites this paper as [712]
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- Authors
- Connolly, S. J., Kerr, C. R., Gent, M., Roberts, R. S., Yusuf, S., Gillis, A. M., Sami, M. H., Talajic, M., Tang, A. S. L., Klein, G. J., Lau, C., & Newman, D. M.
- Affiliations
- McMaster University (CA)
- University of British Columbia (CA)
- University of Calgary (CA)
- McGill University (CA)
- Montreal Heart Institute (CA)
- University of Ottawa (CA)
- Western University (CA)
- University of Toronto (CA)
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2000-05-11
- Volume
- 342
- Issue
- 19
- Pages
- 1385-1391
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- OpenAlex
- W2332653577
- Cited by
- 775
- References
- 16
- Citations by year
- 2026: 8 · 2025: 9 · 2024: 8 · 2023: 16 · 2022: 14 · 2021: 14 · 2020: 21 · 2019: 19 · 2018: 23 · 2017: 15 · 2016: 26 · 2015: 25 · 2014: 23 · 2013: 28 · 2012: 35
- FWCI
- 31.24
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac pacing and defibrillation studies
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Health and Mental Health
- Keywords
- physiological pacing, ventricular pacing, dual-chamber pacemaker, atrial pacing, bradycardia, pacemaker implantation, stroke, cardiovascular mortality, atrial fibrillation, heart failure hospitalization, perioperative complications, symptomatic bradycardia
- MeSH terms
- Aged, Atrial Fibrillation, Bradycardia, Cardiac Pacing, Artificial, Cardiovascular Diseases, Female, Heart Block, Humans, Male, Pacemaker, Artificial, Risk, Stroke
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