The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 60:603-604 (2005)
© 2005 The Gerontological Society of America
Patients, Mean Age 70 Years, With Automatic Implantable Cardioverter-Defibrillators Treated With Dual-Chamber Rate Responsive Pacing (DDDR-70) Have a Higher Mortality Than Patients With Backup Ventricular Pacing (VVI-40) at 3.7-Year Follow-Up
Rishi Sukhija,
Wilbert S. Aronow,
Carmine Sorbera,
Kiran Yalamanchili and
Martin Cohen
Department of Medicine, Cardiology Division, Westchester Medical Center/New York Medical College, Valhalla.
Address correspondence to Wilbert S. Aronow, MD, FGSA, Cardiology Division, New York Medical College, Macy Pavilion, Room 138, Valhalla, NY 10595. E-mail: wsaronow{at}aol.com
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Abstract
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Background. One study showed in 506 patients with automatic implantable cardioverter-defibrillators (AICDs) that the mortality at 1-year follow-up was 6.5% with ventricular backup pacing at 40/minute (VVI-40) versus 10.1% in patients with dual-chamber rate responsive pacing at 70/minute (DDDR-70).
Methods. We performed a retrospective study to determine all-cause mortality in all patients at a university hospital who had AICDs without indications for antibradycardia pacing. Of 535 patients, mean age 70 ± 12 years, 271 patients had backup ventricular pacing with a VVI-40, and 264 patients had dual-chamber rate responsive pacing with a DDDR-70.
Results. At 3.7-year mean follow-up, all-cause mortality was 19% (50 of 264 patients) in patients with DDDR-70 pacing versus 11% (29 of 271 patients) with VVI-40 pacing (p <.01).
Conclusion. Because of the increased mortality, increased cost, and complexity for dual-chamber rate responsive pacing in patients with AICDs, concomitant DDDR pacing at a rate of 70/minute in patients without an indication for antibradycardia pacing is not warranted.
AUTOMATIC implantable cardioverter-defibrillators (AICDs) have been demonstrated to reduce all-cause mortality in patients at high risk for mortality because of life-threatening ventricular arrhythmias (1–6). The American College of Cardiology/American Heart Association/North American Society for Pacing and Electrophysiology guidelines state that there are 5 Class I indications for therapy with an AICD (7).
In the Dual Chamber and VVI Implantable Defibrillator (DAVID) Trial, 506 patients with indications for an AICD without indications for antibradycardia pacing had an AICD with dual-chamber rate-responsive pacing capability implanted (8). Of the 506 patients, 256 patients were randomized to have the AICDs programmed to ventricular backup pacing at a rate of 40/minute (VVI-40), and 250 patients were randomized to have dual-chamber rate responsive pacing at a rate of 70/minute (DDDR-70). At 1-year follow-up, all-cause mortality was 6.5% for VVI-40 patients versus 10.1% for DDDR-70 patients (a 61% insignificant increase in mortality) (8).
Because of the data from the DAVID Trial and also the increased cost and complexity of dual-chamber pacing, we performed a retrospective analysis to determine all-cause mortality at long-term follow-up in all of the patients at a university hospital who had AICDs without indications for antibradycardia pacing who had VVI-40 pacing versus DDDR-70 pacing.
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METHODS
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We performed a retrospective analysis to determine all-cause mortality at long-term follow-up in all patients at a university hospital who had Class I indications for AICDs (7) without indications for antibradycardia pacing. Of the 535 patients, 271 patients (51%) had backup ventricular pacing with a VVI-40 pacer, and 264 patients (49%) had dual-chamber rate-responsive pacing with a DDDR-70 pacer.
The 535 patients included 430 men and 105 women, mean age 70 ± 12 years (range 14–91 years). Mean follow-up was 3.7 years (range 0.5–7.9 years). The chi-square test was used to analyze dichotomous variables.
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RESULTS
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Table 1 shows all-cause mortality in patients, mean age 70 years, with AICDs and VVI-40 versus DDDR-70 pacing. Table 1 also lists the level of statistical significance.
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Table 1. All-Cause Mortality in Patients, Mean Age 70 Years, With Automatic Implantable Cardioverter-Defibrillators and Backup Ventricular Pacing (VVI-40) Versus Dual-Chamber Rate Responsive Pacing (DDDR-70).
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DISCUSSION
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In the DAVID Trial of 506 patients, mean age 65 years, who had AICDs, patients randomized to DDDR-70 pacing had a 61% insignificantly higher mortality than patients randomized to VVI-40 pacing at 1-year follow-up (8). In the present study of 535 patients, mean age 70 years, who had Class I indications for AICDs without indications for antibradycardia pacing, patients who had DDDR-70 pacing had a 73% significantly higher mortality (p <.01) than did patients who had VVI-40 pacing at 3.7-year mean follow-up.
Three reasons why DDDR pacing may increase mortality (8) are: 1) atrial pacing increases heart rate, 2) the PR interval is decreased due to ventricular pacing at the end of the AV interval, and 3) ventricular electrical activation proceeds from the right ventricular apex instead of through the existing conduction system. Pacing-induced cardiac dyssynchrony may cause substantial detrimental physiologic changes. Loss of coordinated ventricular contraction causes a decrease in stroke volume and an increase in left ventricular end-systolic volume and wall stress. Late lateral left ventricular contraction delays overall cardiac relaxation (9). Ventricular dyssynchrony may also produce significant mitral insufficiency caused by sequential rather than simultaneous papillary muscle contraction.
These adverse physiologic changes in conjunction with increased heart rate caused by unnecessary atrial pacing and a shortened PR interval which reduces the atrial systolic period may exacerbate myocardial ischemia, heart failure, and atrial arrhythmias (10). Thus, overall mortality can be adversely affected.
In conclusion, because of the increased mortality, cost, and complexity from dual-chamber pacing in AICDs, the available data suggest that concomitant DDDR pacing at a rate of 70/minute in patients without an indication for antibradycardia pacing is not warranted.
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Footnotes
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Decision Editor: John E. Morley, MB, BCh
Received March 4, 2004
Accepted March 18, 2004
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References
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- The Antiarrhythmics versus Implantable Defibrillators (AVID) Investigators. A comparison of antiarrhythmic-drug therapy with implantable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias. N Engl J Med. 1997;337:1576-1583.[Abstract/Free Full Text]
- Connolly SJ, Gent M, Roberts RS, et al. Canadian Implantable Defibrillator Study (CIDS). A randomized trial of the implantable cardioverter defibrillator against amiodarone. Circulation. 2000;101:1297-1302.[Abstract/Free Full Text]
- Kuck KH, Cappato R, Siebels J, Ruppel R, for the CASH Investigators. Randomized comparison of antiarrhythmic drug therapy with implantable defibrillators in patients resuscitated from cardiac arrest. The Cardiac Arrest Study Hamburg (CASH). Circulation. 2000;102:748-754.[Abstract/Free Full Text]
- Moss AJ, Hall WJ, Cannom DS, et al. Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. N Engl J Med. 1996;335:1933-1940.[Abstract/Free Full Text]
- Buxton AE, Lee KL, Fisher JD, Josephson ME, Prystowsky EN, Hafley G, for the Multicenter Unsustained Tachycardia Trial Investigators. A randomized study of the prevention of sudden death in patients with coronary artery disease. N Engl J Med. 1999;341:1882-1890.[Abstract/Free Full Text]
- Moss AJ, Zareba W, Hall WJ, et al. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med. 2002;346:877-883.[Abstract/Free Full Text]
- Gregoratos G, Abrams J, Epstein AE, et al. ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices: Summary Article. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/NASPE Committee to Update the 1998 Pacemaker Guidelines). Circulation. 2002;106:2145-2161.[Free Full Text]
- The DAVID Trial Investigators. Dual-chamber pacing or ventricular backup pacing in patients with an implantable defibrillator. The Dual Chamber and VVI Implantable Defibrillator (DAVID) Trial. JAMA. 2002;288:3115-3123.[Abstract/Free Full Text]
- Park RC, Little WC, O'Rourke RA. Effect of alteration of left ventricular activation sequence on the left ventricular end-systolic pressure-volume relation in closed chest dogs. Circ Res. 1985;57:706-717.[Abstract/Free Full Text]
- Franz MR, Cima R, Wang D, Proffit D, Kurz R. Electrophysiological effects of myocardial stretch and mechanical determinants of stretch-activated arrhythmias. Circulation. 1992;86:968-978.[Abstract/Free Full Text]
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