Ventricular Pacing or Dual-Chamber Pacing for Sinus-Node Dysfunction

doi:10.1056/NEJMoa013040

Volume 346:1854-1862		June 13, 2002		Number 24

Ventricular Pacing or Dual-Chamber Pacing for Sinus-Node Dysfunction

Gervasio A. Lamas, M.D., Kerry L. Lee, Ph.D., Michael O. Sweeney, M.D., Russell Silverman, M.D., Angel Leon, M.D., Raymond Yee, M.D., Roger A. Marinchak, M.D., Greg Flaker, M.D., Eleanor Schron, M.S., R.N., E. John Orav, Ph.D., Anne S. Hellkamp, M.S., Stephen Greer, M.D., John McAnulty, M.D., Kenneth Ellenbogen, M.D., Frederick Ehlert, M.D., Roger A. Freedman, M.D., N.A. Mark Estes, III, M.D., Arnold Greenspon, M.D., Lee Goldman, M.D., for the Mode Selection Trial in Sinus-Node Dysfunction

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ABSTRACT

Background Dual-chamber (atrioventricular) and single-chamber(ventricular) pacing are alternative treatment approaches forsinus-node dysfunction that causes clinically significant bradycardia.However, it is unknown which type of pacing results in the betteroutcome.

Methods We randomly assigned a total of 2010 patients with sinus-nodedysfunction to dual-chamber pacing (1014 patients) or ventricularpacing (996 patients) and followed them for a median of 33.1months. The primary end point was death from any cause or nonfatalstroke. Secondary end points included the composite of death,stroke, or hospitalization for heart failure; atrial fibrillation;heart-failure score; the pacemaker syndrome; and the qualityof life.

Results The incidence of the primary end point did not differsignificantly between the dual-chamber group (21.5 percent)and the ventricular-paced group (23.0 percent, P=0.48). In patientsassigned to dual-chamber pacing, the risk of atrial fibrillationwas lower (hazard ratio, 0.79; 95 percent confidence interval,0.66 to 0.94; P=0.008), and heart-failure scores were better(P<0.001). The differences in the rates of hospitalizationfor heart failure and of death, stroke, or hospitalization forheart failure were not significant in unadjusted analyses butbecame marginally significant in adjusted analyses. Dual-chamberpacing resulted in a small but measurable increase in the qualityof life, as compared with ventricular pacing.

Conclusions In sinus-node dysfunction, dual-chamber pacing doesnot improve stroke-free survival, as compared with ventricularpacing. However, dual-chamber pacing reduces the risk of atrialfibrillation, reduces signs and symptoms of heart failure, andslightly improves the quality of life. Overall, dual-chamberpacing offers significant improvement as compared with ventricularpacing.

Source Information

From the Division of Cardiology, Mount Sinai Medical Center, and the University of Miami School of Medicine, Miami Beach, Fla. (G.A.L.); the Duke Clinical Research Institute and Duke University School of Medicine, Durham, N.C. (K.L.L., A.S.H.); Brigham and Women's Hospital and Harvard Medical School, Boston (M.O.S., E.J.O.); Heart Care Center, Fayetteville, N.Y. (R.S.); Emory University and Crawford Long Hospital, Atlanta (A.L.); University Hospital, London, Ont., Canada (R.Y.); Lankenau Hospital, Wynnewood, Pa. (R.A.M.); University of Missouri Hospital and Clinics, Columbia (G.F.); the Division of Epidemiology and Clinical Applications, National Heart, Lung, and Blood Institute, Bethesda, Md. (E.S.); and the Department of Medicine, University of California at San Francisco, San Francisco (L.G.).

Other authors were Stephen Greer, M.D. (Baptist Medical Center, Little Rock, Ark.), John McAnulty, M.D. (Oregon Health Sciences University, Portland), Kenneth Ellenbogen, M.D. (Medical College of Virginia, Richmond), Frederick Ehlert, M.D. (St. Luke's–Roosevelt Medical Center, New York), Roger A. Freedman, M.D. (University of Utah Health Sciences Center, Salt Lake City), N.A. Mark Estes III, M.D. (New England Medical Center, Boston), and Arnold Greenspon, M.D. (Thomas Jefferson University Hospital, Philadelphia).

Address reprint requests to Dr. Lamas at Cardiovascular Associates of Miami, 4300 Alton Rd., Suite 207, Miami Beach, FL 33140, or at glamas{at}msmc.com.

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Related Letters:

Cardiac Pacing for Sinus-Node Dysfunction
Blackman B. T., Lamas G. A., Lee K. L., Goldman L.
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N Engl J Med 2002; 347:1891-1892, Dec 5, 2002. Correspondence

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