By Dr Jonathan Shurlock, edited by Dr Ahmed El-Medany
Dr Margaret Infield and colleagues have explored the role of accelerated pacing, with personalised backup heart rates, in patients with heart failure with preserved ejection fraction (HFpEF) and pre-existing pacemakers. The group set out to identify the impact of adjusted pacing settings on quality of life, activity levels, and atrial fibrillation (AF) burden.
The trial was blinded and randomised and enrolled patients from the University of Vermont Medical Centre pacemaker clinic. 170 participants were randomised into personalised accelerated pacing, or usual care with a standard back up rate of 60 beats per minute, and followed up for one year. For the personalised treatment group, the pacing heart rate was calculated using a study specific algorithm incorporating resting heart rate, height, and ejection fraction. The personalised accelerated pacing group included 50 participants,with 57 in the usual care group (The median (IQR) age was 75 (69-81) years, and 48 (48%) were female).
The primary outcome measure was change in Minnesota Living with Heart Failure Questionnaire (MLHFQ) score. Secondary outcome measures included change in N-terminal pro–brain natriuretic peptide (NT-proBNP) levels, pacemaker-detected physical activity, AF from baseline, and adverse clinical events.
Median pacemaker-detected heart rate was higher in the personalised accelerated group, compared with the usual care group 75 (75-80) bpm versus 65 (63-68), at one year follow-up. MLHFQ scores improved in the intervention group over 1 year follow up (median [IQR] baseline MLHFQ score, 26 [8-45]; score at 1 month, 15 [2-25]; score at 1 year, 9 [4-21]; P < .001). Interestingly the opposite was true in the usual care group, whereby scores deteriorated over 1 year follow up (median [IQR] baseline MLHFQ score, 19 [6-42]; score at 1 month, 23 [5-39]; score at 1 year, 27 [7-52]; P = .03).
There was a decrease in NT-proBNP levels in the intervention group, compared with an increase in the control group (mean [SD] decrease of 109  pg/dL vs increase of 128  pg/dL with usual care; P = .02). Activity levels increased in the intervention group and fell in the usual care group (mean [SD], +47  minutes per day with personalised pacing vs −22  minutes per day with usual care; P < .001).There were 4 adverse events in the intervention group, compared with 11 in the usual care group.
The authors concluded that in their study population, personalised pacing improved quality of life, physical activity, and other markers of disease while remaining safe. The data presented suggest there may be a role for a personalised pacing approach. Interestingly in the usual care group all outcome measures were worse over the 1 year of follow up, including self assessed quality of life and activity levels. This has implications for the standard of care for patients with HFpEF more generally, which needs to be considered when exploring novel interventions.
See the full study here: https://pubmed.ncbi.nlm.nih.gov/36723919/