CLINICAL RESEARCH: ELECTROPHYSIOLOGY
High incidence of pacemaker syndrome in patients with sinus node dysfunction treated with ventricular-based pacing in the Mode Selection Trial (MOST)
Mark S. Link, MD*,*,
Anne S. Hellkamp, MS ,
N. A. Mark Estes, III, MD*,
E. John Orav, PhD ,
Kenneth A. Ellenbogen, MD ,
Bassiema Ibrahim, MD||,
Arnold Greenspon, MD¶,
Carlos Rizo-Patron, MD#,
Lee Goldman, MD**,
Kerry L. Lee, PhD,
Gervasio A. Lamas, MD MOST Study Investigators
* Tufts-New England Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
Medical College of Virginia, Richmond, Virginia, USA
|| Winthrop University Hospital Cardiology, Mineola, New York, USA
¶ Jefferson Medical College, Philadelphia, Pennsylvania, USA
# Cardiology Associates, Lubbock, Texas, USA
** Department of Medicine, University of California, San Francisco, California, USA
Division of Cardiology, Mount Sinai Medical Center-Miami Heart Institute, Miami Beach, Florida, USA
Manuscript received June 20, 2003;
revised manuscript received September 29, 2003,
accepted October 15, 2003.
* Reprint requests and correspondence: Dr. Mark S. Link, Tufts-New England Medical Center, Box #197, 750 Washington Street, Boston, Massachusetts 02111, USA.
MLink{at}tufts-nemc.org
OBJECTIVES: We evaluated the incidence, predictors, and treatment of pacemaker syndrome in patients with sinus node dysfunction treated with ventricular-based (VVIR) pacing in the Mode Selection Trial (MOST).
BACKGROUND: Pacemaker syndrome, or intolerance to VVIR pacing, consists of cardiovascular signs and symptoms induced by VVIR pacing.
METHODS: The definition of pacemaker syndrome required that a patient with single-chamber VVIR pacing develop either congestive signs and symptoms associated with retrograde conduction during VVIR pacing or a  20 mm Hg reduction of systolic blood pressure during VVIR pacing, associated with reproducible symptoms of weakness, lightheadedness, or syncope.
RESULTS: Of 996 patients randomized to VVIR pacing, 182 (18.3%) met criteria for pacemaker syndrome in follow-up. Pacemaker syndrome occurred early in most patients (13.8% at 6 months, 16.0% at 1 year, increasing to 19.7% at 4 years). Baseline univariate predictors of pacemaker syndrome included a lower sinus rate and higher programmed pacemaker rate. Previous heart failure, ejection fraction, and drop in systolic blood pressure with VVIR pacing at implantation did not predict the development of pacemaker syndrome. Post-implantation predictors of pacemaker syndrome were a higher percentage of paced beats, higher programmed low rate, and slower underlying spontaneous sinus rate. Quality of life decreased at the time of diagnosis of pacemaker syndrome and improved with reprogramming to atrial-based pacing.
CONCLUSIONS: Severe pacemaker syndrome developed in nearly 20% of VVIR-paced patients and improved with reprogramming to the dual-chamber pacing mode. Because prediction of pacemaker syndrome is difficult, the only way to prevent pacemaker syndrome is to implant atrial-based pacemakers in all patients.
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Abbreviations and Acronyms
| | AV | = atrioventricular | | CTOPP | = Canadian Trial of Physiologic Pacing | | CI | = confidence interval | | DDDR | = dual-chamber pacing | | HR | = hazard ratio | | MOST | = Mode Selection Trial | | SF-36 | = 36-item Short Form | | VA | = ventriculoatrial | | VVIR | = ventricular-based (pacing) |
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