Implication of ventricular pacing burden and atrial pacing therapies on the progression of atrial fibrillation: A systematic review and meta-analysis of randomized controlled trials

Dian A. Munawar, Rajiv Mahajan, Thomas A. Agbaedeng, Anand Thiyagarajah, Darragh J. Twomey, Kashif Khokhar, Catherine O'Shea, Glenn D. Young, Kurt C. Roberts-Thomson, Muhammad Munawar, Dennis H. Lau, Prashanthan Sanders

Research output: Contribution to journalArticlepeer-review

2 Citations (Scopus)


Background: Atrial fibrillation (AF) is common after pacemaker implantation. However, the impact of pacemaker algorithms in AF prevention is not well understood. Objective: The purpose of this study was to evaluate the role of pacing algorithms in preventing AF progression. Methods: A systematic search of articles using the PubMed and Embase databases resulted in a total of 754 references. After exclusions, 21 randomized controlled trials (8336 patients) were analyzed, comprising studies reporting ventricular pacing percentage (VP%) (AAI vs DDD, n = 1; reducing ventricular pacing [RedVP] algorithms, n = 2); and atrial pacing therapies (atrial preference pacing [APP], n = 14; atrial antitachycardia pacing [aATP]+APP, n = 3; RedVP+APP+aATP, n = 1). Results: Low VP% (<10%) lead to a nonsignificant reduction in the progression of AF (hazard ratio [HR] 0.80; 95% confidence interval [CI] 0.57–1.13; P =.21; I2 = 67%) compared to high VP% (>10%). APP algorithm reduced premature atrial complexes (PAC) burden (mean difference [MD] –1117.74; 95% CI –1852.36 to –383.11; P =.003; I2 = 67%) but did not decrease AF burden (MD 8.20; 95% CI –5.39 to 21.80; P =.24; I2 = 17%) or AF episodes (MD 0.00; 95% CI –0.24 to 0.25; P =.98; I2 = 0%). Similarly, aATP+APP programming showed no significant difference in AF progression (odds ratio 0.65; 95% CI 0.36–1.14; P =.13; I2 = 61%). No serious adverse events related to algorithm were reported. Conclusion: This meta-analysis of randomized controlled trials demonstrated that algorithms to reduce VP% can be considered safe. Low burden VP% did not significantly suppress AF progression. The atrial pacing therapy algorithms could suppress PAC burden but did not prevent AF progression.

Original languageEnglish
Pages (from-to)1204-1214
Number of pages11
JournalHeart Rhythm
Issue number8
Publication statusPublished or Issued - Aug 2019


  • Arial preference pacing
  • Atrial fibrillation
  • Atrial pacing therapies
  • Minimize ventricular pacing
  • Reduced ventricular pacing

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

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