Key result
Minimizing atrial pacing at 40 bpm fails to reduce AF incidence compared to standard pacing.
Why the study?
High percentages of atrial pacing have been associated with an increased risk of atrial fibrillation, but whether atrial pacing minimization reduces AF incidence in sinus node dysfunction was unknown.
Does minimizing atrial pacing (DDD-40) reduce the incidence of atrial fibrillation in patients with sinus node dysfunction compared to standard pacing (DDDR-60)?
RCT (n=540)
Open-label
1:1 basis, stratified for sex and prior atrial fibrillation and/or atrial flutter
Yes
Does minimizing atrial pacing (DDD-40) reduce the incidence of atrial fibrillation in patients with sinus node dysfunction compared to standard pacing (DDDR-60)?
Hazard Ratio: 0.97 (95% CI 0.76–1.25)
Absolute Event Rate: 46% vs 46%
p-value: p=.83
Minimizing atrial pacing by programming a base rate of 40 bpm without rate-adaptive pacing does not reduce atrial fibrillation and increases the risk of syncope in patients with sinus node dysfunction.
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Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“I think many of us involved in pacing thought for many years that minimizing pacing would be beneficial, and this clearly shows it is not.”
“Patients with sinus node disease often have atrial fibrillation. There are some observational studies showing that higher percentage of atrial pacing is associated with a higher risk of atrial fibrillation. Whether or not this is due to a prolongation and abnormal activation of the atrium or [whether] these patients just have more progressive disease and therefore are in need of more atrial pacing is not known. Therefore, we had the question, does minimized atrial pacing in patients with sinus node dysfunction reduce the risk of atrial fibrillation?”
“Programming intended to minimize atrial pacing should not be used as routine in unselected patients with SND.”
Minimizing atrial pacing does not reduce atrial fibrillation and increases syncope risk; challenges observational data linking higher atrial pacing to AF.
Frausing et al. (2023) conducted an RCT in Sinus node dysfunction (n=540). Pacing programmed to a base rate of 40 bpm without rate-adaptive pacing (DDD-40) vs. Pacing programmed to a base rate of 60 bpm with rate-adaptive pacing (DDDR-60) was evaluated on Time to first device-detected episode of atrial fibrillation lasting longer than 6 min (HR 0.97, 95% CI 0.76-1.25, p=.83). Minimizing atrial pacing with a base rate of 40 bpm without rate-adaptive pacing did not reduce the incidence of atrial fibrillation compared to standard pacing (HR 0.97).