Anti-bradycardia pacing-impact on patients with HFpEF: a systematic review

Abstract

Heart failure with preserved ejection fraction (HFpEF) has become an emerging concern. The protective effect of bradycardia in patients with reduced ejection fraction using beta-blockers or ivabradine does not improve symptoms in HFpEF. This review aims to assess current data regarding the impact of anti-bradycardia pacing in patients with HFpEF. A search was conducted on PubMed, ScienceDirect, Springer, and Wiley Online Library, selecting studies from 2013 to 2023. Relevant and eligible prospective studies and randomized controlled trials were included. Functional status, quality of life, and echocardiographic parameters were assessed. Six studies conformed to the selection criteria. Four were prospective studies with a total of 90 patients analyzed. Two were randomized controlled trials with a total of 129 patients assessed. The 6-min walk test (6MWT) and the Minnesota Living with Heart Failure Questionnaire (MLHFQ) score improved in all prospective studies. My-PACE trial showed improvements in MLHFQ score (p < 0.001), significant relative lowering in NT-proBNP levels (p = 0.02), and an increased mean daily activity in the personalized accelerated pacing group compared to usual care. RAPID-HF trial proved that pacemaker implantation to enhance exercise heart rate (HR) did not improve exercise capacity and was associated with increased adverse events. HFpEF requires a more individualized approach and quality of life management. This review demonstrates that higher resting HR by atrial pacing may improve symptoms and even outcomes in HFpEF, while a higher adaptive rate during exertion has not been proven beneficial.

Keywords: Cardiac pacing; HFpEF; Heart rate; Left ventricular diastolic dysfunction; Pacemaker.

Fig. 1

The relationship between HR and LVEDP at baseline (median: 66 bpm in HFpEF, 72 bpm in control), 100 bpm, and 120 bpm in patients with HFpEF and control [7]. Graphics program used: Microsoft Corporation. (2018). Microsoft Excel. Retrieved from https://office.microsoft.com/excel

Fig. 2

PRISMA study selection flow diagram. Graphics program used: Microsoft Corporation. (2018). Microsoft Word. Retrieved from https://office.microsoft.com/word

Fig. 3

Influence of the HR on pathophysiology of HFpEF patients a. During rest HR, LVEDP, and wall thickness are increased at any volume due to passive stiffness. b. Increased HR during rest, using a pacemaker, LVEDP decreases due to enhanced myocardial contraction and relaxation. c. During exercise, LVEDP increases because of higher HR along with SNS activation [, , –16]. HR, heart rate; LVEDP, left ventricular end-diastolic pressure; SNS, sympathetic nervous system. Graphics program used: Adobe Inc. (2019). Adobe Illustrator. Retrieved from https://adobe.com/products/illustrator