A perspective on the emerging preventive and therapeutic strategies in pacemaker-induced cardiomyopathy: a systematic review of the literature

PURPOSE OF REVIEW: Pacing-induced cardiomyopathy (PiCM) significantly impacts patient morbidity and mortality, emphasizing the need for improved preventive and therapeutic strategies. This systematic review aimed to evaluate the effectiveness of resynchronization therapies compared with traditional right ventricular pacing (RVP). RECENT FINDINGS: Emerging evidence supports the use of biventricular cardiac resynchronization therapy (BiV-CRT) and conduction system pacing (CSP) as effective alternatives to conventional RVP. Both strategies preserve ventricular synchrony, improve left ventricular (LV) function, and reduce adverse outcomes. Comparative studies suggest superior physiological and clinical benefits of CSP over BiV-CRT, including greater improvements in QRS duration, LV ejection fraction (LVEF), and functional status. In addition, pharmacological therapy-particularly, combination ACEi/ARB with β blockers-has shown potential in reducing the incidence of PiCM. SUMMARY: We conducted a systematic review (inception to August 2025), including 22 studies (2 randomized trials, 20 observational) which met inclusion criteria. BiV-CRT and CSP significantly improved LVEF and NYHA class, with CSP demonstrating incremental advantages in selected cohorts. Preventive approaches, especially CSP and medical therapy, lowered PiCM incidence in high-risk patients with elevated pacing burden. Despite these advances, heterogeneity in PiCM definitions, patient selection, and follow-up durations limit cross-study comparability. Future research should focus on standardizing diagnostic criteria, refining risk stratification, and developing individualized algorithms that integrate device-based and pharmacological strategies for optimal PiCM prevention and management.