Compared to single chamber ventricular pacemakers, dual chamber pacemakers may reduce the incidence of complications in people with sick sinus syndrome and atrioventricular block

Dretzke J, Toff WD, Lip GYH, Raftery J, Fry-Smith A, Taylor RRS

Published Online:

January 21, 2009

Sick sinus syndrome (SSS) and atrioventricular block (AV block) are the two most common reasons people have pacemakers implanted. Both involve the heart beating abnormally slowly. Pacemakers replace or control the heart's own electrical activity. Single chamber pacemakers work on one of the chambers (sections) of the heart, while dual chamber pacemakers, which are more expensive, work on two simultaneously. The review of trials found that dual chamber pacemakers tended to prevent more subsequent heart problems than single chamber ventricular pacemakers. The impact on people's overall quality of life is uncertain. The review did not investigate the relative benefits or risks of surgery to upgrade to a dual chamber pacemaker.

Abstract (click to read)

Background:

Dual chamber pacing or single chamber atrial pacing ('physiologic' pacing) is believed to have an advantage over single chamber ventricular pacing in that it resembles cardiac physiology more closely by maintaining atrioventricular (AV) synchrony and dominance of the sinus node, which in turn may reduce cardiovascular morbidity and mortality thus contributing to patient survival and quality of life. However, a significant proportion of pacemakers currently implanted are single chamber ventricular pacemakers.

Objectives:

The objective of this review was to assess the short- and long-term clinical effectiveness of dual chamber pacemakers compared to single chamber ventricular pacemakers in adults with AV block, sick sinus syndrome or both. An additional objective was to assess separately any potential differences in effectiveness between dual chamber pacing and single chamber atrial pacing. The clinical effectiveness of single chamber atrial pacing versus single chamber ventricular pacing was not examined.

Search strategy:

The Cochrane Controlled Trials Register (The Cochrane Library Issue 3, 2002), MEDLINE (1966 to 2002), EMBASE (1980 to 2002) and the Science Citation Index (1980 to 2002) were searched on 19th August 2002. Citation lists and web sites were checked and researchers in the field contacted.

Selection criteria:

Parallel group or crossover randomised controlled trials of at least 48 hours duration comparing dual chamber pacing and single chamber ventricular pacing, and investigating cardiovascular morbidity, mortality, patient related quality of life, exercise capacity and complication rates.

Data collection and analysis:

Data was extracted onto pre-piloted data extraction forms. Quality assessment was undertaken using a checklist, with a sub-sample of quality data independently extracted by a second reviewer. Where appropriate data was available, meta-analysis was performed. Where meta-analysis was not possible, the number of studies showing a positive, neutral or negative direction of effect and statistical significance were simply counted.

Main results:

Five parallel and 26 crossover randomised controlled trials were identified. The quality of reporting was found to be poor. Pooled data from parallel studies shows a statistically non-significant preference for physiologic pacing (primarily dual chamber pacing) for the prevention of stroke, heart failure and mortality, and a statistically significant beneficial effect regarding the prevention of atrial fibrillation (odds ratio (OR) 0.79, 95% CI 0.68 to 0.93). Both parallel and crossover studies favour dual chamber pacing with regard to pacemaker syndrome (parallel: Peto OR 0.11, 95% CI 0.08 to 0.14; crossover: standardised mean difference (SMD) -0.74, 95% CI - 0.95 to -0.52). Pooled data from crossover studies shows a statistically significant trend towards dual chamber pacing being more favourable in terms of exercise capacity (SMD -0.24, 95% CI -0.03 to -0.45). No individual studies reported a significantly more favourable outcome with single chamber ventricular pacing.

Authors' conclusions:

This review shows a trend towards greater effectiveness with dual chamber pacing compared to single chamber ventricular pacing, which supports the current British Pacing and Electrophysiology Group's Guidelines regarding atrioventricular block. Additional randomised controlled trial evidence from ongoing trials in this area will further inform the debate.

This record should be cited as:

Dretzke J, Toff WD, Lip GYH, Raftery J, Fry-Smith A, Taylor RRS. Dual chamber versus single chamber ventricular pacemakers for sick sinus syndrome and atrioventricular block. Cochrane Database of Systematic Reviews 2004, Issue 2. Art. No.: CD003710. DOI: 10.1002/14651858.CD003710.pub2

Assessed as up to date:

February 25, 2004

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Primary Review Group:

Heart Group

Health topics:

Heart & circulation > Arrythmias

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Compared to single chamber ventricular pacemakers, dual chamber pacemakers may reduce the incidence of complications in people with sick sinus syndrome and atrioventricular block

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