Prior Pacemaker Implantation and Outcomes in HFpEF

Study Questions:

What is the relationship between prior pacemaker implantation and outcomes in patients with heart failure with preserved ejection fraction (HFpEF)?


The study cohort was comprised of pooled patients from the CHARM-Preserved (Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity), I-PRESERVE (Irbesartan in Heart Failure With Preserved Ejection Fraction), and TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) trials. The primary outcome was a composite of cardiovascular (CV) death or HF hospitalization in CHARM-Preserved, all-cause death or CV hospitalization in I-PRESERVE, and a composite of CV death and HF hospitalization or aborted cardiac arrest in TOPCAT. In the present study, the authors investigated the association between pacemaker implantation and risk of primary composite of CV death or HF hospitalization, and the individual components of the composite, and the two main modes of CV death (i.e., sudden death and pump failure death), and all-cause death.


The analysis included 8,466 HFpEF patients after exclusions; of these, 682 patients (8%) had permanent pacemakers at baseline. The study authors found that 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. Patients with a device had a high prevalence of atrial fibrillation, as well as greater use of digoxin and mineralocorticoid receptor antagonist therapy than patients without a pacemaker. The rate of the primary composite outcome in pacemaker patients was almost twice that in patients without a pacemaker (13.6 vs. 7.6 per 100 patient-years of follow-up, respectively), with a similar finding for HF hospitalizations (10.8 vs. 5.1 per 100 patient-years, respectively). This risk rate persisted after adjusting for other prognostic variables (hazard ratio [HR] for the composite outcome, 1.17; 95% confidence interval [CI], 1.02-1.33; p = 0.026), driven mainly by HF hospitalization (HR, 1.37; 95% CI, 1.12-1.60; p < 0.001). The risk of mortality was not significantly higher in pacemaker patients in the adjusted analyses. There were few differences in the risk of sudden death according to history of pacemaker implantation. By contrast, pump failure death was more common in patients with a pacemaker than in those without (1.8 vs. 0.8 per 100 patient-years, respectively); however, the elevated risk did not persist after adjustment for other prognostic variables (fully adjusted HR, 1.00; 95% CI, 0.70-1.42; p = 0.99).


The study authors concluded that right ventricular pacing-induced left ventricular dyssynchony may be detrimental in HFpEF patients.


This retrospective study suggests that cardiac resynchronization therapy may be preferable to right ventricular pacing in patients with HFpEF. Randomized, prospective studies are needed to validate these findings.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Heart Failure and Cardiac Biomarkers

Keywords: Arrhythmias, Cardiac, Atrial Fibrillation, Blood Pressure, Body Mass Index, Cardiac Resynchronization Therapy, Death, Sudden, Digoxin, Geriatrics, Glomerular Filtration Rate, Heart Arrest, Heart Failure, Hospitalization, Mineralocorticoid Receptor Antagonists, Natriuretic Peptide, Brain, Pacemaker, Artificial, Peptide Fragments, Stroke Volume

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