Europace Advance Access originally published online on October 3, 2007
Europace 2007 9(11):1024-1030; doi:10.1093/europace/eum170
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ATRIAL PACING
Increased base rate of atrial pacing for prevention of atrial fibrillation after implantation of a dual-chamber pacemaker: insights from the Atrial Overdrive Pacing Study
1 Drexel University College of Medicine, Philadelphia, PA, USA; 2 University of Utah, Salt Lake City, UT, USA; 3 Las Cruces Memorial Medical Center, Las Cruces, NM, USA; 4 Central Baptist Hospital, Lexington, KY, USA; 5 Lancaster Heart Foundation, Lancaster, PA, USA; 6 Duke University, Durham, NC, USA; 7 St Luke’s Hospital, Kansas City, MO, USA; 8 CVPH Medical Center, Plattsburgh, NY, USA; 9 St Jude Medical CRMD, Sylmar, CA, USA
Manuscript submitted 11 March 2007. Accepted after revision 11 June 2007.
* Corresponding author: Department of Cardiology, The University of Texas Houston Medical School, 6431 Fannin, MSB 1.246, Houston, TX 77030, USA. Tel: +1 713 500 6590; fax: +1 713 500 6556. E-mail address: bkantharia{at}yahoo.com
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Abstract |
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Aims: Different pacing sites and various algorithms have been utilized to prevent atrial fibrillation (AF) in pacemaker recipients. However, the optimal pacing rate settings have not yet been established. In this randomized, prospective, multicentre, single-blinded, cross over study, rate-adaptive pacing at a high base rate (BR) in patients, age 60 years or above, or a history of paroxysmal AF, who underwent dual-chamber (DDD) pacemaker implantation for standard pacing indications, was evaluated for prevention of AF.
Methods and results: In the study cohort of 145 patients implanted with DDD pacemakers with a programmable rest rate (RR) feature, the BR/RR settings were sequentially but randomly adjusted as follows: 60 bpm/Off for the baseline quarter (initial 3 months) and then to either ‘A–B–C’ or ‘C–B–A’ settings (A = 70/65 bpm, B = 70/Off, C = 80/65 bpm) for the subsequent quarters each of 3 months duration. Data on automatic mode switch episodes, device diagnostics, and a questionnaire evaluating pacemaker awareness and palpitations were collected. Ninety-nine patients, mean age 77 ± 10 years, who completed the study protocol and followed for 12 months did not show significant differences in the number of mode switch episodes between any settings used. The percentage of atrial pacing was lower during baseline pacing compared to settings A, B, and C (P < 0.0001). Setting C produced a higher percentage of atrial pacing than A and B (P < 0.01). Although a higher percentage of atrial pacing correlated with a lower incidence of mode switch episodes, there was no statistically significant difference in the number of mode switch episodes between settings A, B, and C. There were no significant differences in the questionnaire scores relating to pacemaker awareness or palpitation.
Conclusion: Overdrive single-site pacing in the right atrium achieved by programming analysed settings in the present study did not reduce AF as assessed by mode switch episodes. Additionally, no change in the symptoms of arrhythmia or awareness of pacing was seen.
Key Words: Atrial fibrillation, Cardiac pacing, Atrial overdrive pacing, Dual-chamber pacemaker
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Introduction |
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Pacemakers play a potentially important role in the non-pharmacological management of atrial fibrillation (AF). Because of significant detrimental effects associated with chronic single-chamber ventricular pacing, atrial-based or dual-chamber (DDD) pacing is generally preferred for patients with chronotropic incompetence.1
–3 This has helped prompt a growing appreciation for the benefit of atrial pacing in the management of AF. Atrial pacing may prevent AF by a number of different mechanisms. These include prevention of bradycardia-induced dispersion of atrial repolarization, suppression of premature atrial contractions (PACs), change in atrial activation patterns, and prevention of electromechanically related atrial stretch.4–6 This has led to a number of studies evaluating the ability of various atrial pacing approaches (including multi-site atrial pacing and different atrial pacing algorithms) to suppress atrial tachyarrhythmias.7–28 In a general pacemaker population, AF not only develops frequently after DDD pacemaker implantations but the burden of AF increases progressively over time.29 With respect to pacing itself, optimal pacing rate settings have not been established. In devices without a dedicated dynamic overdrive pacing algorithm, simply increasing the lower rate of pacing by using high base rate (BR) pacing results in constant pacing at high rates throughout the day, even during periods of rest when the body would normally revert to a lower heart rate. The persistent high pacing rate when the patient is at rest may not be desirable. The advent of rate adaptive pacing has enabled the development of a Rest Rate (RR) algorithm which allows certain pacemakers manufactured by St. Jude Medical (California, USA) to pace at rates below the BR when the patient is resting or sleeping. The algorithm uses activity sensor data to determine if the patient is resting and then lowers the pacing rate to the programmed RR. Activity variance is a time dependent measure of the variation in the sensor signal between consecutive activity readings. The device continuously collects activity variance over a running 7-day window in what is referred to as the Activity Variance Histogram. The device uses the Activity Variance Histogram in combination with sensor data in order to determine if the patient is resting or active. If the most recent activity variance measurement is less than pre-determined threshold within the activity variance and the activity sensor measures no activity, the device will enter RR immediately. If the activity sensor detects activity, the device will exit RR and return to the BR or sensor indicated rate. With such rate-adaptive pacing technology to the point of mimicking the circadian variation in normal heart rate through the use of different pacing rates for activity and rest, it should theoretically be possible to programme these parameters so as to ensure a high percentage of atrial pacing, thus reducing the potential for AF. Such an approach would not require the extra leads and programming challenges of multi-site atrial pacing, the manipulation of manufacturer-specific atrial pacing algorithms, or even necessitate a change in the standard positioning of atrial leads. Thus, it might be possible to achieve a high percentage of atrial pacing and suppress AF by strategic adjustment of activity and RR alone.
We hypothesized that by simple BR/RR programming the incidence of AF would be reduced in patients who were implanted with DDD pacemakers. Accordingly, we conducted this study in patients who received DDD pacemakers for standard indications to evaluate the ability of BR/RR programming to reduce AF episodes.
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Methods |
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General
This was a prospective, multicentre, randomized, single-blinded, crossover study. Approval was obtained from the Institutional Review Board for human research at each participating centre. A complete list of investigators and participating institutions is shown in the Appendix. Written informed consent was obtained from all subjects. Patients of age 60 years or older or a history of paroxysmal AF and a standard indication for DDD pacemaker implantation per conventional guidelines30
were included in this study. Exclusion criteria were as follows: (i) cardiac surgery within the preceding 6 months, (ii) a standard indication for an implantable defibrillator, and (iii) inability to provide informed consent or participate in follow-up. Pre-implant assessment included detailed medical history and physical examination, a 12-lead ECG and a transthoracic echocardiogram. We also examined the impact of our pacing protocol on patients’ awareness of their pacemakers.
Devices used
All patients received DDD pacemakers, Affinity® model 5330, Integrity® model 5342 and Identity® model 5370 (St. Jude Medical) capable of ‘Auto Rest Rate’ algorithm. While two of the pacemakers (Integrity and Identity) offer an AF SuppressionTM algorithm that provides automatic atrial overdrive in response to high intrinsic atrial rates, this feature was not used during the study in order to permit assessment of a simpler approach to preventing AF using differential BR/RR programming. The choice of pacing leads was left to the discretion of implanting physicians. The atrial leads were implanted at the right atrial appendage, a conventional atrial lead placement site where optimal sensing of P waves of >1.0 mV was obtained. Although for the study protocol purpose only BR/RR parameters were controlled, programming of the atrial sensitivity of 0.5 mV, post-ventricular atrial blanking period of 100 ms, and atrial tachycardia detection rate (ATDR) at 225 bpm, were encouraged.
Study sample size
In order to achieve 80% power of detecting a mean difference of 25 automatic mode switch (AMS) between patients with and without atrial overdrive pacing (significance level = 0.05) using one group, two sided paired t test, it was estimated that a minimal sample size of 128 patients would be required. Expecting that some of the patients may not be able to complete the study for various reasons, it was estimated that 
150 patients would need to be enrolled to meet the study sample size requirement. It has been suggested that the cross over studies utilizing device AF burden or AF frequency endpoint may require a little over 150 patients followed for 6 months to detect a 30% therapy efficacy.31 Also given the high variability of atrial tachyarrhythmias and AF recurrence, the present study would only be regarded as a ‘pilot study’.
Study design
Patients were randomized into two groups, each progressing through four quarters of 3-month periods of pacing using different combinations of BR/RR settings (Figure 1). Device programming was completed at the start of each quarter of 3-month period. During the first quarter, all devices were programmed to a BR of 60 bpm and RR to ‘off’ to provide a baseline; after this, in order to avoid any bias based on treatment order, one group progressed through the device settings in A–B–C order, and the other in C–B–A order (BR/RR in A = 70/65 bpm, B = 70/off bpm, and C = 80/65 bpm, respectively). Clinical and demographic data were collected at implant and every 3 months for the 12-month study period. Device diagnostics and AMS episodes were collected. A questionnaire to assess the level of pacemaker awareness and palpitations (using a 1–5 scale, 1 = none of the time, 2 = a little of the time, 3 = some of the time, 4 = most of the time, and 5 = all the time) was completed by patients at each follow-up visit. Patients were blinded to the rate settings of their pacemakers throughout the study. At the end of 12-month follow-up, both the BR and RR were programmed to an optimal setting for the patient according to the physician’s discretion.
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End points
The primary end point was the number of AMS episodes recorded by pacemaker diagnostics. Because of the technical limitations inherent to the devices used, the AMS frequency rather than total AMS burden was used as the primary end point. The AMS duration were not easily obtained as a specific data field. Rather the AMS diagnostics separated episodes as counts within bins of specific AMS duration ranges for all AMS episodes. AMS burden in times would only be an estimated calculation using midpoints within these bins. The secondary end points were arrhythmic episodes and symptoms, level of patient discomfort or symptoms, percentage of atrial pacing and related adverse events.
Determination of atrial fibrillation
The number of AMS detected upon pacemaker interrogation served as the surrogate for episodes of AF. Mode switch episodes were tabulated for each follow-up visit. Because of the potential shortcoming of AMS counts in accurate representation of AF, we performed a closer examination of the data whenever more than 250 mode switches were observed between follow-ups. Inappropriate mode switches were then defined as any events that occurred at a rate near the ATDR and were less than 1 min in duration and were excluded from the analysis.
Statistical analysis
Statistical analyses were made using SAS System for Windows 8.0 Software (SAS Institute, Inc. Cary, NC. USA). The number of AMS episodes, AMS frequency, and the percentage of atrial pacing (PAP) were compared between the four different groups of BR/RR settings. Comparisons of these variables for each group were made using Wilcoxon rank sum test. Regression analyses were also used to evaluate statistical models for the PAP and for logarithm transformed AMS episodes and frequency due to skewness of the data. Spearman correlation was used to assess the relationship between the number of AMS episodes and PAP. For all calculations, a two-sided P-value <0.05 was considered statistically significant.
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Results |
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Patient characteristics
From a cohort of 145 study patients at 17 centres, 99 patients, 59 men, and 40 women (mean age 77 ± 10 years) completed the entire follow-up period (51 in the A–B–C group, and 48 in the C–B–A group).The dropouts from the study were primarily due to loss to follow-up. The baseline characteristics of the study population are provided in Table 1.
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Device pacing/sensing and lead impedances parameters
There was no significant difference in the atrial and ventricular pacing capture and sensing thresholds and the lead impedances at implant, 3, 6, 9, and 12 months (Table 2).
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Number of automatic mode switch episodes
There were no significant differences in the total numbers of AMS episodes during any of the pacing treatment assignments (Table 3). The PAP was significantly lower during baseline pacing than during pacing at settings A, B, and C (P < 0.0001), and setting C produced a significantly higher PAP than settings A and B (P < 0.01). Correlation analysis demonstrated an inverse relationship between the PAP and the number of AMS episodes, with the higher percentage associated with a lower incidence of AMS episodes (r = –0.26, P < 0.03). When broken into discrete bins of percentage of atrial pacing, AMS frequency was significantly reduced as the PAP increased (P < 0.01, Figure 2). There were 35 patients (35%) who had no AMS during the baseline period. Among these patients, 15 (15.2%), 19 (19.2%), and 19 (19.2%) patients had AMS during A, B, and C settings through the study.
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Pacemaker awareness and palpitations
Table 4 shows responses to the follow-up questionnaire. There were no significant differences in questionnaire scores relating to pacemaker awareness or palpitations.
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Discussion |
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The main finding of our study is that there was no significant difference in the occurrence of AF as assessed by the total numbers of AMS episodes during any of the pacing treatment assignments. Our primary goal in this study was to assess the potential of a very simplistic approach to providing atrial overdrive (i.e. using a slightly elevated base pacing rate) to suppress AF in patients who receive DDD pacemakers. Despite the increase in PAP achieved, and its association with a decreased incidence of mode switching, overall this approach failed to reduce AF as measured by AMS counts. This lack of effect was further supported by factorial ANOVA analyses performed on AMS counts with regard to the factors of BR and RR, in which the main effects of these factors were insignificant.
An inadequate duration of overdrive pacing could have accounted for the lack of beneficial effect seen in this study. Even with the most aggressive BR setting of 80 bpm (setting C), atrial pacing was achieved only 79% of the time. This is in contrast to a significantly higher percentage of atrial pacing (mean of 92.9%) in the treatment group that was observed in the Atrial Dynamic Overdrive Pacing Trial (ADOPT) study, in which the AF Suppression algorithm reduced symptomatic AF burden by 25%.32 However, in the Atrial Therapy Efficacy and Safety Trial (ATTEST) study, despite increasing atrial pacing from 75% to 98% by activation of the preventive pacing algorithm, there was no benefit in suppressing AF.23 Neither of these studies evaluated the percent of ventricular pacing as a confounding variable. The potentially adverse impact of an increased percent of ventricular pacing on the incidence of AF was not recognized at the time that these studies were performed. It is now appreciated that an increased percentage of ventricular pacing may negate the effect of any automatic or fixed atrial overdrive algorithms.
In keeping with our goal of evaluating a simple approach to AF prevention, the atrial leads in our study were placed in the right atrial appendage, a location widely used in clinical practice. No attempt was made to select a unique site, such as Bachmann’s bundle or the interatrial septum. Delfaut et al.27 demonstrated that in combination with antiarrhythmic agents, simply a single site DDDR pacing at the high right atrium with a lower rate between 80 and 90 bpm reduced recurrent AF as compared to the baseline state of no pacing, although there was significantly additional benefit of AF reduction with dual site (high right atrium and the coronary ostial site) pacing. Bailin et al.19 reported a reduction in AF progression by pacing in the region of Bachmann’s bundle compared to pacing in the right atrial appendage and postulated that the benefit might result from a reduction in the interatrial conduction time. Longer interatrial conduction time coupled with greater dispersion of atrial refractoriness forms a substrate for atrial arrhythmias ranging from PACs to AF. In light of this, pacing from the right atrial appendage, while a standard location for atrial pacing, may have negated the potential benefit of atrial overdrive in our study. Although, in a larger multicentre, randomized study, the Atrial Septal Pacing Efficacy Clinical Trial (ASPECT), septal pacing did not diminish AF frequency or burden in spite of reducing PACs,25 the Overdrive Atrial Septum Stimulation (OASES) trial showed a better efficacy of the AF suppression overdrive pacing algorithm when the atrial pacing lead was implanted in the low atrial septum.28 In a yet to be published OASES trial it was shown that during right atrial appendage or low septal pacing in conventional DDDR pacing mode had no impact on the cumulative time in atrial tachyarrhythmias, however, when AF suppression overdrive atrial pacing algorithm was activated achieving atrial pacing for 95% of the time, there was a significantly lower atrial tachyarrhythmia burden with septal pacing.28
It is also possible that the lack of favourable response to atrial overdrive pacing observed in our study is secondary to its relatively short follow-up time. In the Canadian Trial of Physiologic Pacing (CTOPP) study, reduction in AF with physiological pacing became apparent only after the first 2 years of follow-up,2 similar to the results of the Danish trial of AAI vs. VVI pacing reported by Andersen et al.1
Our results are in contrast to prior smaller studies of atrial overdrive pacing.7–12 No clear consensus has been reached regarding the beneficial effect of atrial overdrive pacing in larger randomized studies,23,24,32 in part because of differences between the algorithms used. In the ATTEST study, no significant alteration in AF burden was observed when atrial overdrive pacing utilized three separate preventive pacing algorithms (atrial preference pacing, atrial rate stabilization, and post-mode switch overdrive pacing).23 In the PAF-PACE (effect of right atrial overdrive pacing in the prevention of symptomatic paroxysmal AF) study, comparison of medium overdrive (pacing at 10–19 bpm >mean heart rate), high overdrive (pacing at 20–29 bpm >mean heart rate), and no pacing showed significant reduction in symptomatic episodes of paroxysmal AF by both medium and high overdrive pacing.24 In the PAF-PACE study, as opposed to other overdrive pacing studies, AAI overdrive pacing protocol was used, and thus there was no ventricular pacing. In the ADOPT study, atrial overdrive pacing utilizing a single dynamic AF suppression algorithm decreased relative AF burden by 25%.32 Results from large multicentre randomized trials, such as the Systemic Trial Of Pacing to Prevent Atrial Fibrillation (STOP AF), are not available at the present time.33 Our findings, however, are similar to a prior study by Ward et al.18 In their relatively small study of 18 patients with 4 different types of pacemakers with different mode-switch algorithms, no difference in AF rate was observed when single-site right atrial overdrive pacing at rates of 60, 75, and 90 ppm were compared. Furthermore, no difference in exercise tolerance, general well-being, functional capacity, or specific symptom prevalence was observed. Additionally, one-third of their patients failed to tolerate pacing at 90 bpm. In our study, although the drop-outs were due to loss of follow-up, it is conceivable that they were caused by severe symptoms during overdrive pacing. Thus, our approach of overdrive pacing may well be highly symptomatic as well.
Limitations
There were several limitations to our study. The sample size of our study cohort was small. Additionally, we relied on pacemaker-defined mode switch episodes as a surrogate for AF. In spite of limitation of AF detection by permanent pacemakers, there are sufficient data of accuracy of mode switch episodes in detecting AF.34–37 In fact, the pacemakers’ mode switch episodes identify patients at risks for death and stroke.38 The devices used in this study automatically switch modes when the filtered atrial rate interval exceeds the ATDR. The filtered atrial rate interval is a calculated value that always tries to mimic the current atrial rate and is based on virtually continuous monitoring of the P-to-P interval. The only time P-waves are ignored is when they occur during the post-ventricular atrial blanking period. This strategy was designed to provide an appropriate response to atrial tachyarrhythmias while avoiding inappropriate mode switching in response to PACs or other brief and non-sustained accelerations in the rate at which atrial events are sensed. In the absence of far-field sensing of ventricular activity on the atrial channel, the mode switch counter represents a relatively sensitive and easily collected index of the incidence of AF.
Documenting AF would have required continuous ECG or Holter monitoring. Our primary intent, however, was to make a quick evaluation using conventional pacing techniques and very simple programming of the potential for arrhythmia suppression. The absence of stored electrograms was also a limiting factor in this respect. Both undersensing and oversensing of AF might have occurred. The lack of stored electrograms by the Affinity and Integrity devices used precluded direct confirmation of inappropriate as well as appropriate mode switches. We attempted to minimize these limitations by taking a closer look at short-duration events that occurred at a rate near the pacemaker’s ATDR, since clinical experience suggests that many of these events occur as a result of far-field R-wave sensing. A similar strategy was employed in the Mode Selection Trial (MOST) study,3 where short AMS episodes were excluded from consideration, and the focus was on high atrial rate episodes lasting more than 5 min.
The study results are also limited due to the fact that there were no ‘wash-out’ periods between different pacing settings. As a result, potential benefit of a particular pacing setting in deceasing the frequency and duration of AF might have continued during the next pacing setting. Such ‘carry-over effects’ might have led to diminish the apparent effectiveness of an effective pacing setting.
Other limitations of our study include an inability to temporally correlate symptomatic episodes with mode switch episodes, and inability to evaluate the diurnal distribution of mode switch episodes. The percentage of ventricular pacing may influence the development of AF; these data were not collected in this study.
Lastly, because of an age criterion (minimum 60 years) for inclusion in the study, the study design might have reduced the study cohort of patients at risk for AF.
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Conclusion |
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On the basis of our study, single-site overdrive pacing from the right atrial appendage achieved by programming a relatively high fixed BR did not reduce AF as assessed by the number of AMS episodes, compared to more conventional pacemaker rate settings. Perhaps better designed large prospective studies involving a higher percentage of atrial pacing, more sophisticated algorithms and/or alternative or multiple atrial stimulation sites may help determine the role of pacing for suppression of AF in a general pacemaker population after implantation of a dual-chamber pacemaker.
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Appendix |
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Investigators and participating institutions
Bradley Banks, Advanced Medical Research, Covington, Louisiana.
David Fitzgerald, Wake Forest School of Medicine, Winston-Salem, North Carolina.
Roger A. Freedman, University of Utah, Salt Lake City, UT.
Glenn Harper, Bryn Mawr Hospital, Bryn Mawr, PA.
David Hoekenga, Las Cruces Memorial Medical Center, Las Cruces, NM.
Bharat K. Kantharia, Drexel University College of Medicine, Philadelphia, PA.
David Kessler, Austin Heart Center, Austin, TX.
Richard Lane, Integris Baptist Medical Center, Oklahoma City, OK.
Thomas Pritchard, Self Memorial Hospital, Greenwood, SC.
Eugene Silva, Rockford Cardiology, Rockford, IL.
Igor Singer, Jewish Hospital, Louisville, KY.
Robert Sorrentino, Duke University, Durham, NC.
David Steinhaus, St. Luke’s Hospital, Kansas City, MO.
Gery Tomassoni, Central Baptist Hospital, Lexington, KY.
Nicholas Twidale, Great Plains Regional Medical Center, Elk City, OK.
Joel M. Wolkowicz, CVPH Medical Center, Plattsburgh, NY.
Seth Worley, Lancaster Heart Foundation, Lancaster, PA.
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Acknowledgements |
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The authors wish to thank Paul A. Levine, MD, for his editorial assistance and Ms S. Huang for assistance with statistical analyses.
Financial support: This study was supported by St. Jude Medical, Sylmar, California, USA.
Conflict of interest: none declared.
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References |
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