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CLINICAL RESEARCH: PACING AND CARDIAC FUNCTION

Abnormal Conduction Increases Risk of Adverse Outcomes From Right Ventricular Pacing

John J. Hayes, MD, FACC^_*,2, Arjun D. Sharma, MD, FACC, John C. Love, MD, FACC, John M. Herre, MD, FACC, Anna O. Leonen, MS^||, Peter J. Kudenchuk, MD, FACC^|| for the DAVID Investigators¹

^_* Marshfield Clinic and Research Foundation, Marshfield, Wisconsin
Regional Cardiology Associates, Sacramento, California
Maine Medical Center, Portland, Maine
Sentara Norfolk General Hospital, Norfolk, Virginia
^|| University of Washington, Seattle, Washington

Manuscript received December 29, 2005; revised manuscript received May 23, 2006, accepted May 30, 2006.

¹ Reprint requests: DAVID Clinical Trial Center, 1107 NE 45th St., Suite 505, Seattle, Washington 98105 (Email: hayes.john{at}marshfieldclinic.org).

² Correspondence: Dr. John J. Hayes, Department of Cardiology, Marshfield Clinic, 1000 N. Oak Avenue, Marshfield, Wisconsin 54449 (Email: davidctc{at}u.washington.edu).

OBJECTIVES: The purpose of this study was to determine whether QRS duration or morphology increased the risk of adverse outcome in the DAVID (Dual Chamber and VVI Implantable Defibrillator) trial.

BACKGROUND: The DAVID trial found an increased risk of the combined end point of death and new or worsening congestive heart failure (CHF) in defibrillator recipients who were paced DDDR-70 versus VVI-40.

METHODS: We analyzed the combined end point in patients with abnormal QRS duration (AbQRS) (110 ms) compared with those with normal QRS duration (NQRS) (<110 ms).

RESULTS: The QRS data were available for 496 of the 506 patients enrolled in the trial, including 223 patients with NQRS (45%) and 273 patients with AbQRS (55%). In patients in whom defibrillators were programmed to pace infrequently (VVI-40), having an NQRS or AbQRS was not an indicator of increased risk of adverse outcome. However, among patients in whom defibrillators were programmed in a manner that promoted more frequent ventricular pacing (DDDR-70), there was a significant adverse interaction with AbQRS; this combination was independently associated with a higher risk for developing CHF or death (p = 0.017).

CONCLUSIONS: Although patients with AbQRS tended to have other risk factors associated with poor outcome, the interaction of QRS duration with ventricular pacing (DDDR-70) independently contributed to a worse outcome and therefore, was a marker of patients in whom such treatment may be harmful. This should not imply that right ventricular pacing in NQRS patients is safe but rather that pacing in the context of an AbQRS is probably best avoided.

Abbreviations and Acronyms   AbQRS = abnormal QRS   CHF = congestive heart failure   DAVID = Dual Chamber and VVI Implantable Defibrillator   ICD = implantable cardioverter-defibrillator   IVCD = intraventricular conduction delay   LBBB = left bundle branch block   MOST = Mode Selection Trial   NQRS = normal QRS   RBBB = right bundle branch block

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