A Double‐Blind Study of Submaximal Exercise Tolerance and Variation in Paced Rate in Atrial Synchronous Compared to Activity Sensor Modulated Ventricular Pacing

Abstract

To assess the variation in paced rate during everyday activity and the importance of atrioventricular synchronization (AV synchrony) for submaximal exercise tolerance, atrial synchronous (DDD) and activity rate modulated ventricular (VVI,R) pacing were compared in 17 patients with high degree AV block. The patients were randomly assigned to either mode and evaluated by treadmill exercise to moderate exertion and by 24-hour Holter monitoring after 2 months in the DDD and VVI,R modes, respectively. At the end of the study, the patients were programmed to the pacing mode corresponding to the preferred study period. During the treadmill test, the mean exercise time to submaximal exertion (Borg 5/10), exertion ratings and respiratory rate did not differ between pacing modes despite a significantly lower ventricular rate in the VVI,R mode. The atrial rate during VVI,R pacing was significantly higher than the ventricular rate, but did not differ from the ventricular rate during DDD pacing. There was a diurnal variation in paced rate in both pacing modes. Paced ventricular rate was, however, higher and variation in paced rate greater in DDD compared to VVI,R pacing. Nine patients preferred the DDD mode, three patients preferred the VVI,R mode, while five subjects did not express any preference. The results from this study indicate that the variation in paced rate during activity sensor-driven VVI,R pacing does not match that during DDD pacing neither during everyday activities nor during submaximal treadmill exercise. Nevertheless, no differences in exercise time, Borg ratings, and respiratory rate during submaximal exercise were found. Thus, for most patients with high degree AV block, DDD and VVI,R pacing seem equally satisfactory for submaximal exercise.

The effectiveness and cost-effectiveness of dual-chamber pacemakers compared with single-chamber pacemakers for bradycardia due to atrioventricular block or sick sinus syndrome: systematic review and economic evaluation

“…58,60,63 The treadmill test was equally used in studies with participants of younger and intermediate ages, and the bicycle ergometer was predominantly used in studies with individuals older than 65 years. The use of the bicycle or treadmill test was not associated with differences in 67 Sulke, 1991 74 Deharo, 1996 62 Mitsuoka, 1988 69 Kenny, 1986 65 Channon, 1994 60 Menozzi, 1990 68 Kamalvand, 1997 64 Jordaens, 1988 50 Hargreaves, 1995 63 Davis, 1985 61 Kristensson, 1985 66 Perrins, 1983 71 Avery, 1994 58 Yee, 1984 77 Saner, 1996 73 Capucci, 1993 59 Oldroyd, 1991 70 Rediker 67 Sulke, 1991 74 Hargreaves, 1995 63 Deharo, 1996 62 Menozzi, 1990 68 Saner, 1996 73 Oldroyd, 1991 65 Channon, 1994 60 Jordaens, 1988 50 Hargreaves, 1995 63 Avery, 1994 58 Rediker reporting benefits, and with both instruments a benefit was found for dual-chamber pacemakers. Conversely, studies that used the 6-minute walking test reported no additional benefit for dualchamber pacing.…”

“…However, this conclusion is not robust, since there were several sources of heterogeneity. There were some 67 Sulke, 1991 74 Mitsuoka, 1988 69 Kamalvand, 1997 64 Davis, 1985 61 Kristensson, 1985 66 Perrins, 1983 71 Yee, 1984 77 Capucci, 1993 59 Oldroyd, 1991 70 Saner, 1996 73 Rediker, 1988 72 Sulke …”

“…An exploration of the possible sources of variation was conducted, with stratification by pacing mode, age of recipients and outcome measure used. There were variations in the type of ventricular pacing mode (seven studies included rate response 62,63,67,68,70,73,76 ) and in the type of dualchamber pacing mode considered, with four studies of rate-modulated dual-chamber 59,64,73,74 and four of VDD pacemakers. 61,66,71,77 Three studies 63,73,74 compared ventricular pacing to two dual-chamber modes and were included in more than one group.…”

Effects of Physiologic Pacing versus Ventricular Pacing on the Risk of Stroke and Death Due to Cardiovascular Causes

“…1 Now, however, sensors are available that provide a means by which an adequate heart-rate response to exercise can be achieved without atrial sensing. 2 The results of several nonrandomized, observational studies of patients with pacemakers have suggested that physiologic pacing may reduce the risk of atrial fibrillation, stroke, and death. [3][4][5][6] A small, randomized study comparing physiologic (atrial) pacing with ventricular pacing in patients with sinus-node disease demonstrated a reduction in the risk of stroke, and extended follow-up showed a reduction in the rates of death and atrial fibrillation as well.…”

MANAGEMENT OF ATRIAL FIBRILLATION, VENTRICULAR ARRHYTHMIAS AND PACEMAKERS IN OLDER PERSONS: Permanent Pacemakers in Older Persons

“…A special type of sinus node dysfunction is chronotropic incompetence, in which there is an inadequate sinus response to exercise or stress. Rate responsive pacemakers have been shown to benefit patients clinically by restoring physiological heart rate during physical activity 1, 29, 30 …”