Hemodynamic and Functional Outcomes of Rate‐Adaptive and Physiologic Pacing in Heart Failure With Preserved Ejection Fraction: A Systematic Review and Meta‐Analysis

Background Exercise intolerance and poor quality of life remain challenges in HFpEF, driven by chronotropic incompetence and left atrial dysfunction. We evaluated whether rate‐adaptive/accelerated pacing (RAAP), targeting these mechanisms, improves hemodynamic, functional, and patient‐reported outcomes. Methods PubMed, Embase, and the Cochrane Library were searched. Outcomes included NT‐proBNP, Minnesota Living with Heart Failure Questionnaire (MLHFQ) score, 6‐min walk distance (6MWD), E/e', and E/A. Within‐group pre–post changes and comparisons with usual care were synthesized separately. Effects are reported as mean differences (MD) or odds ratios (OR) with 95% confidence intervals (CI). Results Eight reports involving 380 patients were included with myPACE overlap handled by one report per cohort per analysis. Within‐group, RAAP was associated with reductions in NT‐proBNP (MD −462.58 pg/mL; 95% CI −891.37 to −33.79), E/A (MD −1.01; −1.19 to −0.83), and E/e' (MD −3.18; −5.65 to −0.72), and improvements in 6MWD (MD +74.10 m; 36.34 to 111.86) and MLHFQ score (MD −17.40 points; −33.06 to −1.74). Compared with usual care, associations favored RAAP for NT‐proBNP (MD −108.51 pg/mL; −118.31 to −98.70), 6MWD (MD +73.36 m; 32.23 to 114.48), MLHFQ score (MD −16.52 points; −24.15 to −8.89), and AF burden (MD −6.13; −7.88 to −4.37). MACE also favored RAAP in an exploratory analysis (OR 0.47; 0.23 to 0.93), whereas peak VO 2 did not differ significantly. Conclusions RAAP was associated with favorable changes in hemodynamic and functional outcomes. These findings support further evaluation of individualized rate modulation in adequately powered randomized trials.