Post-Pacemaker Implant QRS Duration and Heart Failure Admission in Patients with Sick Sinus Syndrome and Complete Atrioventricular Block

Q: What are the key findings of this study?

Post-pacemaker pacing QRS duration ≥163 ms independently predicted heart failure admission (HR 3.506, 95% CI 1.491-8.247, P=0.004), with no difference between CAVB and SSS groups (P=0.647).

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Sick sinus syndrome (SSS) or complete atrioventricular block (CAVB) undergoing permanent pacemaker implantation (n=604). Intervention: Post-pacemaker implant pacing QRS duration >=163 ms (and Complete Atrioventricular Block vs Sick Sinus Syndrome) vs. Post-pacemaker implant pacing QRS duration <163 ms (and Sick Sinus Syndrome). Primary outcome: Heart failure (HF) admission (HR 3.506, 95% CI 1.491-8.247, p=0.004).

Q: What does this research mean for the field?

Post-pacemaker pacing QRS duration ≥163 ms independently predicts heart failure admission, whereas the incidence of heart failure admission does not differ between patients with sick sinus syndrome and complete atrioventricular block despite differences in ventricular pacing percentage. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Wei‐Chieh Lee; Hsiu‐Yu Fang; Huang‐Chung Chen; Yung‐Lung Chen; Tzu‐Hsien Tsai; Kuo‐Li Pan; Yu‐Sheng Lin; Mien‐Cheng Chen

doi:10.1002/ehf2.12445

May 20, 2019ESC Heart FailureOpen Access

Post-Pacemaker Implant QRS Duration and Heart Failure Admission in Patients with Sick Sinus Syndrome and Complete Atrioventricular Block

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Key result

Paced QRS duration ≥163 ms is linked to ~3.5-fold higher heart failure admission risk.

HR 3.506
95% CI 1.491-8.247
P=0.004
n=604

Figures

Why the study?

Demand ventricular pacing percentages differ between patients with sick sinus syndrome and complete atrioventricular block, but differences in heart failure admission and pacing-induced cardiomyopathy remained uncompared.

Does the incidence of heart failure admission and pacing-induced cardiomyopathy differ between patients with complete atrioventricular block and sick sinus syndrome after pacemaker implantation, and does post-implant pacing QRS duration ≥163 ms predict heart failure admission?

Key Points

To compare the incidence of heart failure admission and pacing-induced cardiomyopathy between patients with sick sinus syndrome and complete atrioventricular block, and to determine predictors of heart failure hospitalization.
Patients with pre-existing heart failure, missing echocardiography data, or significant coronary artery disease were excluded.
Ventricular pacing percentage, pacing QRS duration, and echocardiographic variables were evaluated over a mean follow-up of 6.6 ± 3.7 years in the sick sinus syndrome group and 6.5 ± 3.6 years in the complete atrioventricular block group.
The complete atrioventricular block group had a higher pacing percentage (83.82 ± 33.06% vs. 39.37 ± 9.17%; P < 0.001) and higher prevalence of follow-up LVEF ≤40% (4.2% vs. 1.3%; P = 0.040), but heart failure admission did not differ significantly between groups (5.5% vs. 4.8%; log-rank P = 0.647).
Multivariate Cox regression identified pacing QRS duration ≥163 ms as an independent predictor of heart failure admission (HR 3.506, 95% CI 1.491-8.247; P = 0.004), along with age (HR 1.121, 95% CI 1.054-1.193; P < 0.001), diabetes mellitus (HR 2.667, 95% CI 1.159-6.136; P = 0.021), and left atrial size (HR 1.070, 95% CI 1.012-1.131; P = 0.018).
Kaplan-Meier analysis demonstrated significantly higher heart failure admission rates in patients with pacing QRS duration ≥163 ms compared to <163 ms at 3.5 years (P = 0.004) and 5 years (P = 0.002).

Study Design

Type

Cohort (n=604)

Multicenter

No

Structured PICO

Does the incidence of heart failure admission and pacing-induced cardiomyopathy differ between patients with complete atrioventricular block and sick sinus syndrome after pacemaker implantation, and does post-implant pacing QRS duration ≥163 ms predict heart failure admission?

P

Population

604 older adults with sick sinus syndrome or complete atrioventricular block undergoing permanent pacemaker implantation with preserved LVEF and free of significant coronary artery disease, followed for approximately 6.5 years.

E

Exposure

Complete atrioventricular block (CAVB) indication for pacemaker (100% dual-chamber DDDR) and post-implant pacing QRS duration ≥163 ms

C

Comparator

Sick sinus syndrome (SSS) indication for pacemaker (76.5% dual-chamber DDDR, 23.5% single ventricular VVIR) and post-implant pacing QRS duration <163 ms

O

Outcome

Heart failure (HF) admission (defined as symptoms of occurrence of HF events of NYHA functional class III or IV in the absence of other alternative diagnoses) or pacing-induced cardiomyopathy (PICM, defined as a ≥10% decrease in LVEF with a resultant LVEF <50%)hard clinical

Main Result

Hazard Ratio: 3.506 (95% CI 1.491–8.247)

Absolute Event Rate: 8.9% vs 2.6%

p-value: p=0.004

In patients without baseline heart failure or coronary artery disease undergoing permanent pacemaker implantation, post-implant paced QRS duration ≥163 ms—rather than pacing indication (CAVB vs. SSS) or pacing percentage alone—is the strongest independent predictor of subsequent heart failure hospitalization.

Limitations

Retrospective study design
Single medical center data
Higher all-cause mortality due to older age of study patients
Absence of baseline and follow-up echocardiographic diastolic parameters
Absence of systolic parameters by speckle tracking echocardiography, potentially underestimating impaired systolic function without decreased LVEF
Retrospective study including data from only one medical centre
High all-cause mortality among study patients due to older age
Absence of systolic parameters by speckle tracking echocardiography, which may underestimate the incidence of impaired systolic function without decreased LVEF

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Implication

Supports paced QRS duration for post-pacemaker HF risk stratification independent of indication; leaves open prospective validation and intervention trials.

Abstract

AIMS: High demand right ventricular pacing may elicit left ventricular systolic dysfunction known as pacing-induced cardiomyopathy, increasing the risks of heart failure (HF) hospitalization. Percentage of demand ventricular pacing is different between patients with sick sinus syndrome (SSS) and those with complete atrioventricular block (CAVB). This study aims to compare the incidence of HF admission and pacing-induced cardiomyopathy between patients with SSS and CAVB. METHODS AND RESULTS: A total of 824 patients who received single ventricular or dual-chamber pacemaker implantation at our hospital between January 2003 and December 2012 were recruited for the study. Patients with HF, those without complete cardiac echocardiography, and those with significant coronary artery disease were excluded. Finally, 315 patients with SSS and 289 patients with CAVB were enrolled in this study. The CAVB group had a higher pacing percentage (39.37 ± 9.17% vs. 83.82 ± 33.06%; P < 0.001), longer pacing QRS duration (142.56 ± 33.02 ms vs. 156.63 ± 25.18 ms; P < 0.001), and higher prevalence of follow-up left ventricular ejection fraction ≤40% (1.3% vs. 4.2%; P = 0.040). However, the incidence of HF admission was similar between the two groups (log-rank P = 0.647). Age [hazard ratio (HR), 95% confidence interval (CI): 1.121, 1.054-1.193], diabetes mellitus (HR, 95% CI: 2.667, 1.159-6.136), pacing QRS duration ≥163 ms (HR, 95% CI: 3.506, 1.491-8.247), and left atrial size (HR, 95% CI: 1.070, 1.012-1.131) were independent predictors of HF admission. The Kaplan-Meier curve showed a significant difference in HF admission over a 3.5 year follow-up period (3.5 years: P value = 0.004; 5 years: P value = 0.002) between patients with pacing QRS duration ≥163 and <163 ms. CONCLUSIONS: There was no difference in HF admission between patients with SSS and CAVB, although the CAVB group had a higher pacing percentage. Post-pacemaker implant pacing QRS duration ≥163 ms was the most important predictor of HF admission.

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Cite This Study

Lee et al. (2019) conducted a cohort in Sick sinus syndrome (SSS) or complete atrioventricular block (CAVB) undergoing permanent pacemaker implantation (n=604). Post-pacemaker implant pacing QRS duration >=163 ms (and Complete Atrioventricular Block vs Sick Sinus Syndrome) vs. Post-pacemaker implant pacing QRS duration <163 ms (and Sick Sinus Syndrome) was evaluated on Heart failure (HF) admission (HR 3.506, 95% CI 1.491-8.247, p=0.004). Post-pacemaker pacing QRS duration ≥163 ms independently predicted heart failure admission (HR 3.506, 95% CI 1.491-8.247, P=0.004), with no difference between CAVB and SSS groups (P=0.647).

synapsesocial.com/papers/6a7340f503bfdad20fc675b6 https://doi.org/10.1002/ehf2.12445

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Post-Pacemaker Implant QRS Duration and Heart Failure Admission in Patients with Sick Sinus Syndrome and Complete Atrioventricular Block

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Post-Pacemaker Implant QRS Duration and Heart Failure Admission in Patients with Sick Sinus Syndrome and Complete Atrioventricular Block

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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