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  •    Atrial fibrillation after pacemaker implantation for sick sinus syndrome is not a major determinant of quality of life.
    Rashaad Chothia, MD.

    Sick sinus syndrome when the sinus node is unable to pace the heart appropriately is an indication for permanent pacemaker placement. Dual Chamber pacemakers are recommended for patients with sick sinus syndrome in sinus rhythm.  With dual chamber DDDR mode, physiological pacing is obtained which attempts to mimic sinus synchrony. The benefit from maintaining atrioventricular synchrony also demonstrates a reduction in development of atrial fibrillation, seen in multiple clinical trials including the MOST trial.  The difference in AV pacing versus ventricular pacing alone has not shown significant differences in mortality although some studies have suggested that dual chamber pacing improves some aspects of health related quality of life.

    How these beneficial effects are mediated remains unclear. Is the decrease in AF the reason for improvement in QOL after dual chamber pacemaker implantation? If so then the development of atrial fibrillation after implantation should cause a decrease in health related quality of life and cardiovascular functional status measurements.

    To address this question the authors analyzed data from the Mode Selection Trial (MOST) using serial QOL, and cardiovascular functional status measurements of 2010 subjects enrolled from 1995 to 1999 implanted with pacemakers, and followed till 2001. The 36-item Short Form General Health Survey and the Specific Activity Scale posed questions to assess physical function, physical role, mental health, emotional role, social function, bodily pain, vitality, and general health perception. Cardiac function was evaluated with question about their ability to perform everyday tasks. The subjects were evaluated at baseline prior to implantation, then at 3 months and 12 months afterwards. The lead author of the substudy analysis was Kirsten E. Fleischmann of The University of California, San Francisco.

    The study itself found a significant improvement in multiple areas of quality of life measured at 12 months after pacemaker implantation. MOST, in contrast to the previous pacemaker trials, found a slight improvement in QOL among patients receiving dual-chamber compared to single-chamber pacemakers. The group who developed AF, paroxysmal or chronic, had similar improvement in results except for a lesser improvement in physical functioning.  In comparison in smaller earlier studies for highly symptomatic AF, pacemakers implanted after AV node ablation, did show marked improvements in QOL.  But in this population with Sick Sinus Syndrome, which is usually older, the effects on QOL associated with AF are quite modest. The analysis from MOST led the authors to conclude: “AF after pacemaker implantation in elderly patients with sick sinus syndrome was not a major determinant of QOL. However there was a trend toward better cardiovascular functional status in patients without PAF or CAF” (Fleischmann et al. Atrial Fibrillation and quality of life after pacemaker implantation for sick sinus syndrome: Data from the Mode Selection Trial (MOST). Am Heart J 2009; 158: 78-83.)

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