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August 20, 2019 Circulation. 2019;140:e382–e482. DOI: 10.1161/CIR.0000000000000628 e416

CLINICAL STATEMENTS AND GUIDELINES Kusumoto et al 2018 Bradycardia Clinical Practice Guidelines

Synopsis

One area of particular interest in the past has been the investigation of optimal pacing mode in SND. Atrialbased pacing modes (AAI and DDD) have been compared with ventricular-based pacing mode (VVI) in 4 major RCTs and reviewed in a recent expert consensus document.S5.4.4.1-1–S5.4.4.1-4,S5.4.4.1-7 Results were inconsistent across the studies and the reconciliation of findings can be challenging. However, atrial-based pacing modes appeared to confer advantage over ventricular-based pacing mode with respect to a lower incidence of AF. The impact of atrialbased pacing modes on the prevention of heart failure or stroke, and improvement in QOL is less clear.S5.4.4.1-8 Recommendation-Specific Supportive Text

1.	 Four trials compared the efficacy of AAI or DDD (collectively known as atrial based) versus VVI (single chamber ventricular) pacing with respect to clinical outcome such as new-onset AF, heart failure hospitalization, stroke incidence, QOL and mortality.S5.4.4.1-1–S5.4.4.1-5 Although the trials were very different with respect to study design, outcome definition, and duration of follow-up, as well as having significant inter-group crossover rates, the most consistent clinical benefit of dual chamber pacing over single chamber ventricular

Figure 6. Chronic SND management algorithm. Colors correspond to Class of Recommendation in Table 2. See Sections 4.3. and 5.4. for discussion. Dashed lines indicate possible optional strategies based on the specific clinical situation. *Symptomatic patients with very infrequent need for pacing for rate support or patients with significant comorbidities. AV indicates atrioventricular; GDMT, guideline-directed management and therapy; PPM, permanent pacemaker; and RV, right ventricular.

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