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Pacemakers and Outcomes in HFpEF Patients
Study Questions:
What is the relationship between pacemaker implantation and clinical outcomes in patients with heart failure with preserved ejection fraction (HFpEF)?
Methods:
This was a retrospective analysis of three large drug trials enrolling patients with HFpEF: CHARM-Preserved, I-PRESERVE, and TOPCAT. The study looked for the association between having a pacemaker and the risk of the primary composite of cardiovascular (CV) death or HF hospitalization, modes of CV death, and all-cause death in unadjusted and adjusted analyses.
Results:
Among 8,466 study subjects, 682 patients (8%) had a pacemaker. Pacemaker patients were older and more often men and had lower body mass indexes, estimated glomerular filtration rates, and blood pressures, but higher concentrations of N-terminal pro–B-type natriuretic peptide than those without a pacemaker. The rate of the primary composite outcome in pacemaker patients vs. those without one was 13.6 vs. 7.6 per 100 patient-years of follow-up. Likewise, HF hospitalization rates were 10.8 vs. 5.1 per 100 patient-years, respectively. This risk rate persisted after adjusting for other prognostic variables, driven mainly by HF hospitalization. The risk of death was not significantly higher in pacemaker patients in the adjusted analyses.
Conclusions:
These findings raise the possibility that right ventricular (RV) pacing-induced left ventricular (LV) dyssynchrony may be detrimental in HFpEF patients.
Perspective:
The authors found that pacemaker implantation was associated with a higher risk of the composite outcome of HF hospitalization or death from CV causes, that this risk persisted after adjustment for other prognostic variables, and that in adjusted analyses, the excess risk was primarily attributable to hospital admission for worsening HF. However, this was not a randomized trial, and there were substantial differences between patients with and those without a pacemaker. Additionally, we do not know what proportion of the patients were RV paced and how much. All these factors render this study merely hypothesis generating. The BLOCK-HF trial found that patients with LVEF ≤50% and significant burden of RV pacing, benefit from cardiac resynchronization therapy (CRT). The key question raised by the present manuscript is whether CRT benefits extend to patients with LVEF >50.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Heart Failure and Cardiac Biomarkers
Keywords: Arrhythmias, Cardiac, Blood Pressure, Body Mass Index, Cardiac Resynchronization Therapy, Geriatrics, Glomerular Filtration Rate, Heart Failure, Natriuretic Peptide, Brain, Pacemaker, Artificial, Peptide Fragments, Secondary Prevention, Stroke Volume
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