Use of ACE inhibitors, ARBs, or β-blockers reduced pacing-induced cardiomyopathy incidence by 41% (HR 0.59) over 10 years in patients with high RV pacing burden.
Can advanced noninvasive cardiac imaging identify patients at high risk for developing pacing-induced cardiomyopathy?
Advanced cardiac imaging techniques such as strain echocardiography and cardiac magnetic resonance can help predict the development of pacing-induced cardiomyopathy and potentially guide the selection of pacing modalities.
Effect estimate: Adjusted HR 0.59 (95% CI 0.45–0.77) for ACEi/ARB/β-blocker therapy reducing PICM incidence (95% CI 0.45–0.77)
Absolute Event Rate: 4.7% vs 7%
p-value: p=<0.001
Background/Objective: Pacing-induced cardiomyopathy (PICM) is a common complication of right ventricular (RV) pacing, affecting 6–25% of patients with frequent RV pacing, due to electrical and mechanical dyssynchrony. Certain clinical and electrocardiographic risk factors have been identified, including high RV-pacing burden and longer paced QRS, but their ability to predict the development PICM remains limited. Additionally, other forms of PICM have been described, including heart failure with preserved ejection fraction and RV failure. The goal of this narrative review is to summarize the current evidence utilizing noninvasive imaging to identify patients predisposed to a high risk of PICM. Methods: Using a literature search in the PubMed, Scopus, Google Scholar, and the Cochrane databases from 2000 to 2025, which included but was not limited to the keywords right ventricular pacing, pacemaker-related cardiomyopathy, pacemaker-induced cardiomyopathy, biventricular pacing, conduction system pacing, His bundle pacing, left bundle pacing, echocardiography, computed tomography imaging, and cardiac magnetic resonance imaging, we reviewed randomized control trials, observational retrospective and prospective cohort studies, societal guidelines, and systematic review articles. Conclusions: Essential in the diagnosis of PICM, cardiac imaging can identify patients at risk, even before left ventricular (LV) dysfunction or symptoms develop. Pre- and early post-implantation 2- and 3-dimensional echocardiography with global longitudinal strain provides sensitive parameters for the potential development of PICM. Relative indices of contractile asymmetry have been described. Cardiac magnetic resonance imaging offers an accurate assessment of cardiac volumes and LV synchrony and can also quantify myocardial fibrosis, a significant predictor of PICM. Performing pre-device implantation imaging may help predict subsequent heart failure development and potentially can guide pacing modality selection that can mitigate this risk. Thus, an imaging-guided framework will advance the management of PICM.
Asturias et al. (Mon,) conducted a review in Adults with high right ventricular pacing burden or conduction system pacing candidates at risk for pacing-induced cardiomyopathy. Advanced cardiac imaging modalities for risk prediction and management of pacing-induced cardiomyopathy vs. Standard diagnostic evaluation without advanced imaging or other pacing modalities was evaluated on Development of pacing-induced cardiomyopathy defined as ≥10% decrease in LVEF to <50% or composite of heart failure hospitalization, mortality, or echocardiographic parameters of cardiomyopathy (Adjusted HR 0.59 (95% CI 0.45–0.77) for ACEi/ARB/β-blocker therapy reducing PICM incidence, 95% CI 0.45–0.77, p=<0.001). Use of ACE inhibitors, ARBs, or β-blockers reduced pacing-induced cardiomyopathy incidence by 41% (HR 0.59) over 10 years in patients with high RV pacing burden.