This vs atrioventricular for block pacing dual-chamber high-grade single-chamber god

Veröffentlicht Gustav Kling | Sonntag, 24. September 2017

The trial was designed to have a power of at least 90 percent to detect a 25 percent reduction in the primary end point, with a target recruitment of patients. In the Pacemaker Selection in the Elderly PASE study, patients 65 years of age or older with sinus-node disease or atrioventricular block were randomly assigned to receive single-chamber ventricular pacing or dual-chamber pacing. Table 2 shows event rates and hazard ratios for death from all causes, death from cardiovascular causes, and specified cardiovascular events for the primary comparison of single-chamber pacing with dual-chamber pacing; also shown are the event rates and hazard ratios for the separate comparison of fixed-rate and rate-adaptive single-chamber pacing with dual-chamber pacing. Exclusion criteria were documented in patients, leaving eligible for the study, of whom In centers that had previously implanted less than 50 percent dual-chamber pacing systems, additional hardware costs were met by a subsidy from the following pacemaker manufacturers and suppliers under an agreement with the International Association of Prosthesis Manufacturers: For fixed-rate single-chamber pacemakers, a rate of 70 beats per minute was suggested.

Address reprint requests to Dr. We are indebted to the many technical, medical, nursing, and clerical staff members who provided support at the participating centers. Superior cardiac hemodynamics of atrioventricular synchrony over rate responsive pacing at submaximal exercise: Relative risk was calculated after adjustment for age, sex, and NYHA class at baseline and expressed as hazard ratios with 95 percent confidence intervals. Jude Medical, and Vitatron and having received lecture fees from St. The United Kingdom Pacing and Cardiovascular Events UKPACE trial compared the clinical benefits of single-chamber ventricular pacing and dual-chamber pacing in elderly patients with atrioventricular block.

Critical Appraisal of Current Data

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Br Heart J ; Stroke, Transient Ischemic Attack, or Thromboembolism. Of those assigned to dual-chamber pacing, Camm reports having received consulting fees and having served on advisory boards for Guidant, St.

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The trial was approved by the North West Multi-Centre Research Ethics Committee and the local research ethics committee for each center. A comparison of the acute and long-term hemodynamic effects of ventricular inhibited and atrial synchronous ventricular inhibited pacing. No patients were lost to follow-up with respect to the primary end point. Of those assigned to single-chamber pacing, It is perhaps counterintuitive that the hemodynamic advantages of atrioventricular synchrony do not result in greater clinical benefit.

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Design and analysis of randomized clinical trials requiring prolonged observation of each patient. Eligible patients were 70 years of age or older and scheduled for their first pacemaker implantations for high-grade i. Dual-chamber pacing or ventricular backup pacing in patients with an implantable defibrillator: In the Canadian Trial of Physiologic Pacing CTOPP , patients 18 years of age or older who had sinus-node disease or atrioventricular block were randomly assigned to physiologic atrial or dual-chamber pacing or single-chamber ventricular pacing. Over three years, dual-chamber pacing is unlikely to influence mortality or the incidence of cardiovascular events, and single-chamber ventricular pacing should be regarded as an acceptable mode. Within the single-chamber group, assignment to fixed-rate or rate-adaptive pacing was randomly determined.

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Prespecified cardiovascular events included atrial fibrillation defined as an episode, with or without symptoms, lasting 15 minutes or more and verified by electrocardiography , new or significantly worsening heart failure, a composite of stroke, transient ischemic attack, or other thromboembolism, revision of the pacing system, new-onset angina or newly diagnosed ischemic heart disease, and myocardial infarction. Of these, This assumed an annual mortality rate of 8 percent in the single-chamber group, with allowance for a 6 percent crossover from single-chamber to dual-chamber pacing. In elderly patients with high-grade atrioventricular block, the mode of pacing has no significant influence on the rate of death from all causes in the first five years after pacemaker implantation. Eighty-three percent of patients were symptomatic. Canadian Trial of Physiological Pacing:

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This capability might also increase the overall likelihood that atrial fibrillation will be detected with these systems, potentially masking a benefit of dual-chamber pacing; however, the diagnostic requirement of an electrocardiographically verified episode lasting 15 minutes or longer would be expected to attenuate the effect of such a bias. One explanation for this may be that intraventricular and interventricular dyssynchrony resulting from stimulation at the right ventricular apex might counteract the benefit of atrioventricular synchrony. Prespecified cardiovascular events included atrial fibrillation defined as an episode, with or without symptoms, lasting 15 minutes or more and verified by electrocardiography , new or significantly worsening heart failure, a composite of stroke, transient ischemic attack, or other thromboembolism, revision of the pacing system, new-onset angina or newly diagnosed ischemic heart disease, and myocardial infarction. Follow-up extended to a mean of 6. For fixed-rate single-chamber pacemakers, a rate of 70 beats per minute was suggested.

Background

Superior cardiac hemodynamics of atrioventricular synchrony over rate responsive pacing at submaximal exercise: Methods In a multicenter, randomized, parallel-group trial, patients 70 years of age or older who were undergoing their first pacemaker implant for high-grade atrioventricular block were randomly assigned to receive a single-chamber ventricular pacemaker patients or a dual-chamber pacemaker patients. The finding that there was a higher rate of stroke, transient ischemic attack, or thromboembolism with fixed-rate ventricular pacing is intriguing.

At the final follow-up or at the study end point, at least One explanation for this may be that intraventricular and interventricular dyssynchrony resulting from stimulation at the right ventricular apex might counteract the benefit of atrioventricular synchrony. At the conclusion of the study, 3. The trial was approved by the North West Multi-Centre Research Ethics Committee and the local research ethics committee for each center. Of those assigned to dual-chamber pacing, A prespecified secondary analysis involved the separate comparisons of fixed-rate and rate-adaptive single-chamber pacing with dual-chamber pacing.

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  1. Deaths were classified as due to cardiovascular or noncardiovascular causes and treated as the result of cardiovascular causes if attributed to old age or if the cause was unclear. J R Stat Soc ; In elderly patients with high-grade atrioventricular block, the mode of pacing has no significant influence on the rate of death from all causes in the first five years after pacemaker implantation. The impact of baseline covariates on the hazard ratio for the primary end point was assessed with the use of the log-rank test. The choice of pacing mode for elderly patients with high-grade atrioventricular block should be made on an individual basis.
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  2. Crossover, in the event of suspected intolerance of the pacing mode, was at the discretion of the investigator. In the Pacemaker Selection in the Elderly PASE study, patients 65 years of age or older with sinus-node disease or atrioventricular block were randomly assigned to receive single-chamber ventricular pacing or dual-chamber pacing. It is perhaps counterintuitive that the hemodynamic advantages of atrioventricular synchrony do not result in greater clinical benefit. No patients were lost to follow-up with respect to the primary end point.
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The choice of pacing mode for elderly patients with high-grade atrioventricular block should be made on an individual basis. Quality of life and clinical outcomes in elderly patients treated with ventricular pacing as compared with dual-chamber pacing. For rate-adaptive single-chamber pacemakers, the suggested lower and upper rate limits were 70 beats per minute and beats per minute, respectively. Deaths and specified cardiovascular events were adjudicated and classified by an independent committee on end points and events, with members unaware of the pacing modes.

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Fixed-rate single-chamber ventricular pacing is associated with an increased risk of stroke, transient ischemic attack, or thromboembolism, but the pacing mode does not otherwise influence the incidence of cardiovascular events in the first three years after pacemaker implantation. Exclusion criteria included chronic established atrial fibrillation, New York Heart Association NYHA class IV heart failure, advanced cognitive dysfunction, total immobility, and advanced cancer life expectancy of less than one year. This article is dedicated to the patients who participated in the trial and to the memory of Prof.

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The extent of ventricular pacing, as assessed from the pacemaker's memory at one month, was recorded for 65 percent of all patients. Eighty-three percent of patients were symptomatic. Conceivably, the lower heart rates associated with fixed-rate pacing might promote atrial stasis, but the finding could be due to the play of chance amid multiple comparisons and should be interpreted with caution.

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