Clinical Trials

Dennis L. DeSilvey, MD, Section Editor Waldo Cardiovascular Medicine, Belfast, ME

Minimizing Ventricular Pacing to Reduce Atrial Fibrillation in Sinus Node Disease

Dennis L. DeSilvey, MD
From Waldo Cardiovascular Medicine, Belfast, ME Address for correspondence: Dennis L. DeSilvey, MD, Waldo Cardiovascular Medicine, Box 287, Belfast, ME 04915 E-mail: ddesilvey@wchi.com

espite an early period of interest in the concept that dual-chamber pacing would help to maintain sinus rhythm in patients with a history of atrial fibrillation (AF) and a need for permanent pacing, this hypothesis has been shown to have only minimal benefit. It is, therefore, exciting when developments in cardiac pacing are such that they may offer hope that pacing can reduce the incidence of AF. The recent paper by Sweeney and colleagues1 presents a study that offers such hope. The Search AV Extension and Managed Ventricular Pacing for Promoting Atrioventricular Conduction (SAVE PACe) trial was a randomized controlled trial sponsored by and extensively supported by the Medtronic Corporation, Minneapolis, MN. The trial was designed to compare a strategy of conventional dual-chamber pacing with the use of a programming technique and design feature of Medtronic pacemakers called dual-chamber minimal ventricular pacing. The latter is a method of automatically lengthening or eliminating the pacemakers atrioventricular (AV) interval to minimize ventricular pacing and, theoretically, prevent ventricular desynchrony due to right ventricular pacing. The feature is akin to atrial demandinhibited pacing without the risk of asystole, should AV conduction fail to occur. The study population included elderly patients, aged 7211 years, and involved 1065 of 1321 screened patients. Screening included an atrial pacing test, which tested for AV conduction of 1:1 up to an atrial pacing rate of 100 beats per minute and also required a QRS duration of 120 ms. Patients with significant degrees of AV block were

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also excluded for obvious reasons. Of the 1321 patients who underwent screening, 214 (83%) did not pass the atrial pacing test. The outcomes of the trial showed that the percentage of paced ventricular beats in the group assigned to dual-chamber minimal ventricular pacing was significantly less than that of the group assigned to conventional dual-chamber pacing (9.1% vs 99.0%). The median percentage of paced atrial beats was similar in the 2 groups (74.1% vs 70.4%). During the follow-up period of 1.7 years, AF developed in 110 patients: 68 of 535 patients in the group assigned to conventional dual-chamber pacing (12.7%) and 42 of 530 in the group assigned to dual-chamber minimal ventricular pacing (7.9%) (P=.004 by log-rank test). Mortality was not significantly different between the 2 groups (4.9% in the group assigned to dualchamber minimal ventricular pacing vs 5.4%), and the rate of hospitalization for heart failure was also not altered by the therapy (2.8% in the group assigned to dual-chamber pacing minimal ventricular pacing and 3.1% in the group assigned to conventional dual-chamber pacing). Patients in whom persistent AF developed had a higher number of hospitalizations for heart failure (7.3% vs 3.2%) and more strokes (4.5% vs 1.8%), which was not statistically significant and also suggests that anticoagulation was not given to all patients in persistent AF because the rate is higher than the 1.7% reported in the warfarin trials. It is increasingly becoming the practice in centers that implant pacemakers to place dual-chamber minimal ventricular pacemakers in most patients in whom AV conduction appears to be intact, and this paper indicates that this is an appropriate action made even more appropriate by the programming

CLINICAL TRIALS

THE AMERICAN JOURNAL OF GERIATRIC CARDIOLOGY 2008 VOL. 17 NO. 1

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The American Journal of Geriatric Cardiology (ISSN 1076-7460) is published bimonthly (Jan., March, May, July, Sept., Nov.) by Le Jacq, a Blackwell Publishing imprint, located at Three Enterprise Drive, Suite 401, Shelton, CT 06484. Copyright 2007 by Le Jacq. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publishers. The opinions and ideas expressed in this publication are those of the authors and do not necessarily reflect those of the Editors or Publisher. For copies in excess of 25 or for commercial purposes, please contact Ben Harkinson at BHarkinson@bos.blackwellpublishing.com or 781-388-8511.

parameters available in current pacing technology. It is also encouraging that the cost of these devices is not greater than, and in many cases is less than, the cost of simpler and probably less effective pacing technology. Newer devices now allow for pace termination of AF and other atrial arrhythmias, giving even greater benefit to the patient as well as

a need for a greater understanding of the available parameters by the following physician. RefeRence
1 Sweeney MO, Bank AJ, Nsah E, et al. Minimizing ventricular pacing to reduce atrial fibrillation in sinus-node disease. N Engl J Med. 2007;357:10001008.

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CLINICAL TRIALS

THE AMERICAN JOURNAL OF GERIATRIC CARDIOLOGY 2008 VOL. 17 NO. 1

The American Journal of Geriatric Cardiology (ISSN 1076-7460) is published bimonthly (Jan., March, May, July, Sept., Nov.) by Le Jacq, a Blackwell Publishing imprint, located at Three Enterprise Drive, Suite 401, Shelton, CT 06484. Copyright 2007 by Le Jacq. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publishers. The opinions and ideas expressed in this publication are those of the authors and do not necessarily reflect those of the Editors or Publisher. For copies in excess of 25 or for commercial purposes, please contact Ben Harkinson at BHarkinson@bos.blackwellpublishing.com or 781-388-8511.