Effects of Physiologic Pacing versus Ventricular Pacing on the Risk of Stroke and Death Due to Cardiovascular Causes

doi:10.1056/NEJM200005113421902

Volume 342:1385-1391		May 11, 2000		Number 19

Effects of Physiologic Pacing versus Ventricular Pacing on the Risk of Stroke and Death Due to Cardiovascular Causes

Stuart J. Connolly, M.D., Charles R. Kerr, M.D., Michael Gent, D.Sc., Robin S. Roberts, M.Tech., Salim Yusuf, M.D., Anne M. Gillis, M.D., Magdi H. Sami, M.D., Mario Talajic, M.D., Anthony S.L. Tang, M.D., George J. Klein, M.D., Ching Lau, M.D., David M. Newman, M.D., for The Canadian Trial of Physiologic Pacing Investigators

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ABSTRACT

Background Evidence suggests that physiologic pacing (dual-chamberor atrial) may be superior to single-chamber (ventricular) pacingbecause it is associated with lower risks of atrial fibrillation,stroke, and death. These benefits have not been evaluated ina large, randomized, controlled trial.

Methods At 32 Canadian centers, patients without chronic atrialfibrillation who were scheduled for a first implantation ofa pacemaker to treat symptomatic bradycardia were eligible forenrollment. We randomly assigned patients to receive eithera ventricular pacemaker or a physiologic pacemaker and followedthem for an average of three years. The primary outcome wasstroke or death due to cardiovascular causes. Secondary outcomeswere death from any cause, atrial fibrillation, and hospitalizationfor heart failure.

Results A total of 1474 patients were randomly assigned to receivea ventricular pacemaker and 1094 to receive a physiologic pacemaker.The annual rate of stroke or death due to cardiovascular causeswas 5.5 percent with ventricular pacing, as compared with 4.9percent with physiologic pacing (reduction in relative risk,9.4 percent; 95 percent confidence interval, –10.5 to25.7 percent [the negative value indicates an increase in risk];P=0.33). The annual rate of atrial fibrillation was significantlylower among the patients in the physiologic-pacing group (5.3percent) than among those in the ventricular-pacing group (6.6percent), for a reduction in relative risk of 18.0 percent (95percent confidence interval, 0.3 to 32.6 percent; P=0.05). Theeffect on the rate of atrial fibrillation was not apparent untiltwo years after implantation. The observed annual rates of deathfrom all causes and of hospitalization for heart failure werelower among the patients with a physiologic pacemaker than amongthose with a ventricular pacemaker, but not significantly so(annual rates of death, 6.6 percent with ventricular pacingand 6.3 percent with physiologic pacing; annual rates of hospitalizationfor heart failure, 3.5 percent and 3.1 percent, respectively).There were significantly more perioperative complications withphysiologic pacing than with ventricular pacing (9.0 percentvs. 3.8 percent, P<0.001).

Conclusions Physiologic pacing provides little benefit overventricular pacing for the prevention of stroke or death dueto cardiovascular causes.

Source Information

From the Departments of Medicine (S.J.C., S.Y.) and Clinical Epidemiology and Biostatistics (M.G., R.S.R.), McMaster University, Hamilton, Ont.; the Department of Medicine, University of British Columbia, Vancouver (C.R.K.); the Department of Medicine, University of Calgary, Calgary, Alta. (A.M.G.); the Department of Medicine, McGill University, Montreal (M.H.S.); the Institut de Cardiologie de Montréal, Montreal (M.T.); the Department of Medicine, University of Ottawa, Ottawa, Ont. (A.S.L.T.); the Department of Medicine, University of Western Ontario, London (G.J.K.); and the Department of Medicine, University of Toronto, Toronto (C.L., D.M.N.) — all in Canada.

Address reprint requests to Dr. Connolly at Hamilton Health Sciences, General Site, McMaster Clinic Rm. 501, 237 Barton St. E., Hamilton, ON L8L 2X2, Canada, or at connostu{at}hhsc.ca.

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Effects of Physiologic Pacing versus Ventricular Pacing
Harthorne J. W., Shibolet O., Amit G., Connolly S. J., Gent M., Kerr C. R., The Canadian Trial of Physiologic Pacing Investigators
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N Engl J Med 2000; 343:1417-1418, Nov 9, 2000. Correspondence

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