Minimising atrial pacing does not reduce the risk for AF in sinus node disease

The risk for atrial fibrillation (AF) was not reduced with minimised atrial pacing in patients with sinus node disease who underwent a first-time pacemaker implantation, according to the DANPACE II trial. In fact, a base pacing rate of 40 bpm without rate-adaptive pacing increased the risk for syncope.

“Sinus node disease and AF often coexist,” stated Dr Mads Brix Kronborg (Aarhus University, Denmark) [1]. “In patients with sinus node disease, a higher percentage of atrial pacing has been linked to an increased risk of AF. Whether this increased risk is caused by abnormal prolongation and propagation of atrial depolarisation induced by pacing or whether it may result from an increased need for pacing in more progressive atrial disease is not known.”

The current DANPACE II trial was designed to determine whether minimising atrial pacing reduces the risk of AF in patients with sinus node dysfunction. Participants (n=539) with sinus node dysfunction undergoing first-time pacemaker implantation were randomised 1:1 to pacing programmed to a base rate of 60 bpm with rate-adaptive pacing (DDDR-60) or pacing programmed to a base rate of 40 bpm without rate-adaptive pacing (DDD-40). The included patients were remotely monitored for 2 years. The primary endpoint was the first device-detected episode of AF lasting over 6 minutes.

The median percentage of atrial pacing was 1% in the DDD-40 arm and 49% in the DDDR-60 arm. However, this reduced atrial pacing did not result in a decreased incidence of AF >6 minutes (46% in both arms; log-rank P=0.83). Furthermore, AF >6 hours was observed in 36% of the participants in the DDD-40 group and 32% of those in the DDDR-60 group (log-rank P=0.35). The corresponding results for AF > 24 hours were 26% for the DDD-40 arm and 21% for the DDDR-60 arm. Syncope or pre-syncope occurred more frequently in the DDD-40 arm (22% vs 13%; log-rank P=0.01). Also, the rate of crossovers was higher in the DDD-40 arm at 23%, compared with 3% in the DDDR-60 arm (log-rank P<0.001).

In conclusion, a reduction in atrial pacing did not lead to a reduction in the incidence of AF in patients with sinus node dysfunction who received a first pacemaker but resulted in a higher rate of syncope.

1. 
   
   1. Kronborg MB, et al. DANPACE II: minimized atrial pacing and risk of atrial fibrillation in sinus node dysfunction. Hot Line Session 7, ESC Congress 2023, 25–28 August, Amsterdam, the Netherlands.

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Posted on 30 October, 202330 October, 2023