Under-utilization of pacemaker therapy for sinus node dysfunction – Real world data from South Asia

Abstract

ObjectiveChronic symptomatic sinus node dysfunction (SND), the most common bradyarrhythmia, can be effectively managed by permanent cardiac pacing. Yet the care pathway and barriers to adoption of pacing therapy are not well understood – particularly in low volume implanting countries. The IMPROVE Brady study is a quality improvement initiative being conducted at centers in South Asia, Latin America, and Russia. We assessed the rates of SND diagnosis and pacemaker treatment for SND in the South Asia cohort.MethodsThe prospective study enrolled patients with heart rate of ≤50 beats per minute presenting with symptoms including syncope, dizziness, and/or dyspnea from ten centers in India and Bangladesh. Patients were followed to identify the proportion diagnosed with SND and subsequently treated with pacemaker therapy.ResultsA total of 508 patients meeting criteria were enrolled and followed on average for 8.3 ± 8.0 months. Patients were on average 58 years of age, 77% were male, and 91% had completed at least primary education. An SND diagnosis was made in 368 (72%) of patients, with the majority (80%) of diagnoses occurring within 1 month of enrollment. Of the patients with an SND diagnosis, 63 (17%) were treated with a pacemaker. Reasons for not receiving treatment were: subject refusal or deferred decision (45%), unaffordability (34%), physician determined – not-indicated (20%), and other (1%). Older age, female gender, history of hypertension, lower resting heart rate, and syncopal or pre-syncopal symptoms were associated with a higher probability of implant.ConclusionsIn a care pathway assessment for the diagnosis and treatment of symptomatic SND in South Asia only 1 in 6 patients received pacemaker indicated therapy, largely due to patient refusal and physician decision. Phase II of the study will be aimed to improve this treatment rate.

Arrhythmia Perception and Quality of Life in Bradyarrhythmia Patients Following Permanent Pacemaker Implantation

“…To date, the number of patients with SND and AF has continued to increase, and they tend to have more comorbidity and severer symptoms than other patients; however, only limited research has been conducted on their treatment patterns and outcomes (Jackson et al, 2016). In addition, only limited research on the PPM care pathway and pacing therapy has been carried out in South Asia, Latin America, and Russia (Narasimhan et al, 2017). Similarly, very few studies have investigated arrhythmia perceptions and health-related QoL in Chinese patients with bradyarrhythmia following PPM implantation.…”

“…Further, the sick sinus syndrome, which is another name for SND, is a sinoatrial node dysfunction that causes symptomatic bradycardia, low cardiac output, and hypo-cerebral perfusion (Patel, Majeed, & Sule, 2017). Bradyarrhythmia, such as AVB, SND, or AF with SVR, often causes symptoms such as syncope, dizziness, dyspnea (Brenner et al, 2017; Narasimhan et al, 2017), chest pain, fatigue (Patel et al, 2017), palpitation, heart fluttering, heart skipping, and headache (Wood, Stewart, Drew, Scheinman, & Frolicher, 2009), which subsequently causes patients’ health-related quality of life (QoL; Jackson et al, 2016) to deteriorate. Health-related QoL refers to changes in an individual’s perceptions of physical and mental health status over time and can affect his or her overall QoL (Lu, Tseng, & Tsai, 2003).…”

Conceptos actuales sobre la clasificación clínica y alteraciones electrofisiológicas en la disfunción del nódulo sinusal

“…Teniendo en cuenta que las taquiarritmias supraventriculares y los eventos tromboembólicos son frecuentes en los pacientes con DNS, se debe considerar el uso de anticoagulación oral y especialmente en aquellos pacientes con fibrilación auricular documentadas (2,9) . La evolución de los pacientes con DNS es variable e impredecible.…”

“…Actualmente se denomina disfunción del nódulo sinusal (DNS) a esta entidad nosológica. Los pacientes con este trastorno son a menudo añosos (aunque algunas publicaciones describen una distribución bimodal) y en general presentan otras comorbilidades (6)(7)(8)(9)(10) .…”

“…Los pacientes a menudo buscan atención médica con síntomas de aturdimiento, presíncope, síncope y, en pacientes con periodos alternantes de bradicardia y taquicardia, palpitaciones u otros síntomas asociados con una frecuencia cardíaca rápida (3)(4)(5) . Debido a que los síntomas pueden ser de naturaleza variable, inespecíficos y frecuentemente transitorios, a veces puede ser difícil establecer esta relación síntomaalteración electrocardiográfica (8)(9)(10) . Los hallazgos electrocardiográficos típicos son uno o más episodios de bradicardia sinusal extrema (Rubenstein Tipo I), o pausas sinusales, paro y bloqueo de salida sinoatrial (Rubenstein Tipo II), o episodios de bradicardia y/o pausas alternantes con taquiarritmias auriculares (Rubenstein Tipo III) (2) .…”