CLINICAL STUDY
Progression to chronic atrial fibrillation after pacing: the Canadian Trial of Physiologic Pacing
Allan C. Skanes, MD*,
Andrew D. Krahn, MD, FACC*,
Raymond Yee, MD, FACC*,
George J. Klein, MD, FACC*,
Stuart J. Connolly, MD, FACCc,
Charles R. Kerr, MD, FACC ,
Michael Gent, DSc ,
Kevin E. Thorpe, MMath,
Robin S. Roberts, MTech for the CTOPP Investigators
* Arrhythmia Service, Division of Cardiology, University of Western Ontario, London, Ontario, Canada
Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
c The Department of Medicine, McMaster University, Hamilton, Ontario, Canada
Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
Manuscript received August 21, 2000;
revised manuscript received March 19, 2001,
accepted March 29, 2001.
Reprint requests and correspondence: Dr. Allan C. Skanes, Arrhythmia Service, London Health Sciences Center, University Campus, 339 Windermere Road, London, Ontario, Canada N6A 5A5
allan.skanes{at}lhsc.on.ca
OBJECTIVES
This study examined the effect of physiologic pacing on the development of chronic atrial fibrillation (CAF) in the Canadian Trial Of Physiologic Pacing (CTOPP).
BACKGROUND
The role of physiologic pacing to prevent CAF remains unclear. Small randomized studies have suggested a benefit for patients with sick sinus syndrome. No data from a large randomized trial are available.
METHODS
The CTOPP randomized patients undergoing first pacemaker implant to ventricular-based or physiologic pacing (AAI or DDD). Patients who were prospectively found to have persistent atrial fibrillation (AF) lasting greater than or equal to one week were defined as having CAF. Kaplan-Meier plots for the development of CAF were compared by log-rank test. The effect of baseline variables on the benefit of physiologic pacing was evaluated by Cox proportional hazards modeling.
RESULTS
Physiologic pacing reduced the development of CAF by 27.1%, from 3.84% per year to 2.8% per year (p = 0.016). Three clinical factors predicted the development of CAF: age  74 years (p = 0.057), sinoatrial (SA) node disease (p < 0.001) and prior AF (p < 0.001). Subgroup analysis demonstrated a trend for patients with no history of myocardial infarction or coronary disease (p = 0.09) as well as apparently normal left ventricular function (p = 0.11) to derive greatest benefit.
CONCLUSIONS
Physiologic pacing reduces the annual rate of development of chronic AF in patients undergoing first pacemaker implant. Age 74 years, SA node disease and prior AF predicted the development of CAF. Patients with structurally normal hearts appear to derive greatest benefits.
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Abbreviations and Acronyms
| | AF | = atrial fibrillation | | AV | = atrioventricular | | CAD | = coronary artery disease | | CAF | = chronic atrial fibrillation | | CI | = confidence interval | | CTOPP | = Canadian Trial Of Physiologic Pacing | | ECG | = electrocardiogram | | LV | = left ventricle or left ventricular | | MI | = myocardial infarction | | QOL | = quality of life | | SA | = sinoatrial | | VVIR | = ventricular-based rate-responsive pacing |
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