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CLINICAL STUDY: ELECTROPHYSIOLOGY

Predictors of stroke in patients paced for sick sinus syndrome

Arnold J. Greenspon, MD, FACC^*,*, Robert G. Hart, MD, David Dawson, MD, Anne S. Hellkamp, MS, Marc Silver, MD, FACC^||, Greg C. Flaker, MD, FACC^¶, Eleanor Schron, MS, RN^#, Lee Goldman, MD, FACC^**, Kerry L. Lee, PhD, Gervasio A. Lamas, MD, FACC MOST Study Investigators

^* Division of Cardiology, Jefferson Medical College and Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
University of Texas, San Antonio, Texas, USA
Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
Duke Clinical Research Institute and Duke University, Durham, North Carolina, USA
^|| Gastonia Memorial Hospital, Gastonia, North Carolina, USA
^¶ University of Missouri, Columbia, Missouri, USA
^# Division of Epidemiology and Clinical Applications, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
^** University of California, San Francisco, San Francisco, California, USA
Mount Sinai Medical Center and the University of Miami School of Medicine, Miami Beach, Florida, USA

Manuscript received May 5, 2003; revised manuscript received August 19, 2003, accepted September 24, 2003.

^* Reprint requests and correspondence: Dr. Arnold J. Greenspon, Jefferson Heart Institute, Jefferson Medical College, 925 Chestnut Street, Philadelphia, Pennsylvania 19107, USA.
arnold.greenspon{at}jefferson.edu

OBJECTIVES: This study was an analysis of factors associated with stroke in a population of patients paced for sinus node dysfunction in a large prospective clinical trial (Mode Selection Trial [MOST]).

BACKGROUND: The effects of dual-chamber versus single-chamber ventricular pacing on subsequent stroke in patients with sinus node dysfunction are not known.

METHODS: A total of 2,010 patients with sinus node dysfunction were randomized to ventricular or dual-chamber pacing and followed for a median of 33.1 months.

RESULTS: The median participant age was 74 years. During 5,664 patient-years of follow-up, 90 strokes (11 hemorrhagic) occurred. By life-table analysis, the rate of stroke was 2.2% (95% confidence interval [CI] 1.6 to 2.9) at one year and 5.8% (95% CI 4.5 to 7.1) at four years. The incidence of stroke was not significantly different in dual-chamber (4%) as compared with ventricular-paced patients (4.9%) (hazard ratio [HR] 0.82, 95% CI 0.54 to 1.25, p = 0.36). Multivariable analysis demonstrated that significant predictors of stroke included prior stroke or transient ischemic attack, Caucasian race, hypertension, prior systemic embolism, and New York Heart Association functional class III or IV (p < 0.05); pacing mode remained non-significant after adjustment for these factors (p = 0.37). Clinically reported atrial fibrillation after implantation was a risk factor for stroke in this cohort after adjustment for other predictors of stroke (p = 0.042, HR 1.68 [95% CI 1.02 to 2.76]).

CONCLUSIONS: Clinical characteristics, but not mode of pacing, were associated with subsequent stroke in patients paced for sinus node dysfunction.

Abbreviations and Acronyms   AF = atrial fibrillation   CI = confidence interval   CTOPP = Canadian Trial Of Physiologic Pacing   DDDR = dual-chamber rate-modulated   MOST = Mode Selection Trial   NYHA = New York Heart Association   TIA = transient ischemic attack   VVIR = ventricular rate-modulated

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