Rate-Responsive Pacing Unmasking Previously Undiagnosed Multivessel Coronary Artery Disease: A Case Report

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Multivessel coronary artery disease and permanent atrial fibrillation with a single-chamber pacemaker (n=1). Intervention: Activation of rate-responsive pacing. Primary outcome: New-onset exertional angina (CCS class III) leading to diagnosis of multivessel coronary artery disease.

Bruno Romstein; Vedran Pašara; Ivan Prepolec; Miroslav Krpan; Vedran Velagić

doi:10.15836/ccar2026.240

November 1, 2026Cardiologia CroaticaOpen Access

Rate-Responsive Pacing Unmasking Previously Undiagnosed Multivessel Coronary Artery Disease: A Case Report

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Key result

Rate-responsive pacing triggers exertional angina, unmasking severe multivessel CAD.

n=1

Key Points

To report a case of new-onset exertional angina following the activation of rate-responsive pacing, leading to the diagnosis of previously unrecognized multivessel coronary artery disease.
Case report evaluating a 70-year-old man with hypertension, diabetes mellitus, dyslipidemia, and permanent atrial fibrillation who had a single-chamber pacemaker implanted in 2013 in VVI mode with a lower rate limit of 50 beats/min.
The generator was replaced in July 2023, rate-responsive pacing was activated in December 2023 after an acute heart failure admission, and diagnostic workup followed two months later for Canadian Cardiovascular Society class III exertional angina.
Echocardiography showed concentric left ventricular hypertrophy with left ventricular ejection fraction of 55–60%, basal inferior wall hypokinesis, and septal dyssynchrony.
Coronary angiography revealed a chronic total occlusion of the proximal dominant right coronary artery with collateral filling, alongside 60% stenoses of the mid left anterior descending artery and proximal first obtuse marginal branch.
Regadenoson stress myocardial perfusion scintigraphy showed reversible perfusion defects across the septal, inferolateral, basal lateral, and apical inferior segments without fixed defects; the patient declined surgery and remained asymptomatic on medical therapy at follow-up in March 2026.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

P

Population

A 70-year-old man with permanent atrial fibrillation, hypertension, diabetes, dyslipidemia, and a single-chamber pacemaker followed for over two years after rate-responsive pacing activation.

E

Exposure

Activation of rate-responsive pacing on a single-chamber pacemaker, followed by diagnostic evaluation (echocardiography, coronary angiography, regadenoson stress test myocardial perfusion scintigraphy) and conservative medical therapy (after declining surgical coronary revascularization).

O

Outcome

New-onset exertional angina (Canadian Cardiovascular Society class III) two months after rate-responsive pacing activation, unmasking multivessel coronary artery disease (chronic total occlusion of the proximal dominant right coronary artery, 60% stenoses of the mid left anterior descending artery and proximal first obtuse marginal branch, and reversible perfusion defects).

Activation of rate-responsive pacing can increase myocardial oxygen demand and unmask previously silent multivessel coronary artery disease by precipitating exertional angina.

Limitations

Single patient case report
Patient declined recommended urgent surgical coronary revascularization

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Implication

Rate-responsive pacing may provoke angina unmasking occult CAD; hypothesis-generating and should not yet change practice.

Abstract

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Cite This Study

Romstein et al. (2026) conducted a case report in Multivessel coronary artery disease and permanent atrial fibrillation with a single-chamber pacemaker (n=1). Activation of rate-responsive pacing was evaluated on New-onset exertional angina (CCS class III) leading to diagnosis of multivessel coronary artery disease. Activation of rate-responsive pacing triggered CCS class III exertional angina, unmasking chronic total RCA occlusion and 60% stenoses in the mid-LAD and OM1.

synapsesocial.com/papers/6af5db300766bb45ea003110 https://doi.org/10.15836/ccar2026.240

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Rate-Responsive Pacing Unmasking Previously Undiagnosed Multivessel Coronary Artery Disease: A Case Report

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Rate-Responsive Pacing Unmasking Previously Undiagnosed Multivessel Coronary Artery Disease: A Case Report

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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