Pacemaker Mode Selection

Introduction to Pacemaker Modes

• The American College of Cardiology recommends the use of DDD pacemakers over VVI pacemakers in most patients requiring ventricular stimulation, as they preserve atrioventricular synchrony, reduce the risk of atrial fibrillation by 20% (HR 0.80), decrease the risk of stroke by 19% (HR 0.81), and prevent pacemaker syndrome in up to 83% of patients with VVI mode 1

Indications for Pacemaker Mode Selection

• The American Heart Association recommends the use of VVI/VVIR pacemakers in patients with persistent or paroxysmal atrial fibrillation or flutter, where there is no significant hemodynamic contribution from the atria (Class I) 4
• The American College of Cardiology recommends the use of DDD/DDDR pacemakers in patients with complete AV block and present atrial complexes, where atrial contribution is needed for hemodynamic benefit (Class I) 4

Clinical Outcomes

• The use of atrial-based pacing reduces the risk of atrial fibrillation by 20% (HR 0.80, 95% CI 0.72-0.89, p<0.0001) compared to ventricular pacing 1
• Atrial-based pacing reduces the risk of stroke by 19% (HR 0.81, 95% CI 0.67-0.99, p=0.035) 1
• Up to 83% of patients with VVI mode develop pacemaker syndrome, with 65% experiencing moderate to severe symptoms 1

Pacemaker Syndrome

• The American College of Cardiology notes that pacemaker syndrome can cause a decrease in systolic volume of up to 50% and an increase in left atrial pressure of up to 25% 6
• Patients with pacemaker syndrome may experience dizziness, fatigue, palpitations, and reduced exercise capacity 6