Personalized Pacing: A New Paradigm for Patients With Diastolic Dysfunction or Heart Failure With Preserved Ejection Fraction - myPACE

Mar 03, 2023
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Author/Summarized by Author:
Dharam J. Kumbhani, MD, SM, FACC
Summary Reviewer:
Deepak L. Bhatt, MD, MPH, MBA, FACC
Date Published:
02/01/2023
Original Posted Date:
03/03/2023
References

Contribution To Literature:

The myPACE trial showed that a personalized accelerated pacing rate (myPACE) resulted in significant improvements in health-related quality of life, as measured by the MLHFQ, compared with the standard lower rate setting of 60 bpm (usual care) among patients with symptomatic HFpEF.

Description:

The goal of the trial was to assess the safety and efficacy of a personalized accelerated pacing algorithm in patients with heart failure and preserved ejection fraction (HFpEF).

Study Design

Patients were randomized in a 1:1 fashion to oral anticoagulation with either personalized backup heart rate setting (myPACE; n = 48) or usual care (60 bpm; n = 52). The myPACE algorithm was designed to provide patients with a customized pacemaker backup rate that is within the normal range of adult resting heart rates. Formula: Personalized heart rate [bpm] = (Height [cm] x -0.37) + 135) x √√ (ejection fraction [%]/50).

  • Total number of enrollees: 100
  • Duration of follow-up: 1 year
  • Median age: 75.5 years
  • Percentage female: 48%

Inclusion criteria:

  • Adults >18 years old with a pacemaker
  • Preclinical and clinical HFpEF based on: N-terminal pro–B-type natriuretic peptide (NT-proBNP) >400 ng/mL in the last 24 months
  • Or HF hospitalization within 2 years, use of loop diuretics for HF, or New York Heart Association class ≥II HF symptoms

OR

  • Echocardiographic evidence of diastolic dysfunction or left ventricular hypertrophy (indexed to body surface area: men >115 g/m2, women >95 g/m2 or indexed to height: >men 49.2 g/m, >women 46.7 g/m)
  • Or relative wall thickness >0.42, or wall thickness >1.2 cm (posterior wall)
  • Or left atrial (LA) dilation (LA volume/body surface area index >28 mL/m2)
  • SSS with intact AV nodal conduction or minimal right ventricular pacing (<150 ms)

Exclusion criteria:

  • Paced QRS duration of >150 ms
  • Infiltrative cardiomyopathy
  • Hypertrophic cardiomyopathy
  • More than moderate valvular stenosis or regurgitation
  • Aortic valve replacement in the past year
  • Significant primary pulmonary disease on home oxygen
  • Uncontrolled hypertension as defined by blood pressure >160/100 mm Hg on two measurements ≥15 minutes apart
  • Creatinine >2 mg/mL or hemoglobin <8 g/dL

Other salient features/characteristics:

  • Stage C HF: 76%
  • Paroxysmal atrial fibrillation: 50%
  • Mean EF: 60%

Principal Findings:

The primary endpoint, change at 1 month and 1 year in Minnesota Living With Heart Failure Questionnaire (MLHFQ) from baseline, for myPACE vs. control, was: -10.9 and -15.0 points vs. -0.6 and +3.5 points (p < 0.001).

Secondary analyses for myPACE vs. control:

  • Change in NT-proBNP at 1 month from baseline: p = 0.02
  • Change in mean daily activity at 1 year from baseline: +47 vs. -22 minutes, p < 0.001
  • Safety events were comparable

Interpretation:

In this small trial, a personalized accelerated pacing rate (myPACE) resulted in significant improvements in health-related quality of life, as measured by the MLHFQ, compared with the standard lower rate setting of 60 bpm (usual care) among patients with symptomatic HFpEF. Improvements in NT-proBNP and physical activity levels were noted. A personalized algorithm may allow for more physiologic changes in heart rate without inducing dyssynchrony. These are interesting results and should be replicated in a larger multicenter trial prior to more widespread adoption.

References:

Infeld M, Wahlberg K, Cicero J, et al. Effect of Personalized Accelerated Pacing on Quality of Life, Physical Activity, and Atrial Fibrillation in Patients With Preclinical and Overt Heart Failure With Preserved Ejection Fraction: The myPACE Randomized Clinical Trial. JAMA Cardiol 2023;8:213-21.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Diabetes and Cardiometabolic Disease, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Echocardiography/Ultrasound, Exercise

Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Echocardiography, Exercise, Geriatrics, Heart Failure, Hypertrophy, Natriuretic Peptide, Brain, Pacemaker, Artificial, Quality of Life, Stroke Volume


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