Rate-dependent threshold changes during atrial pacing: clinical and experimental studies

In 36 patients undergoing a permanent right atrial pacing for the treatment of sick sinus syndrome and/or atrioventricular block, the stimulation threshold was determined at a wide range of pacing rates (60 to 120 beats/min) 7 to 10 days after the lead implantation. Twenty-nine (80%) of these cases showed rate-dependent threshold changes, with significantly lower thresholds at higher than lower pacing rates (e.g., 2.91 +/- 1.01 mA at 70 beats/min and 2.32 +/- 0.75 mA at 120 beats/min, P less than 0.01). Thus, with a fixed, smaller current strength, the stimuli often failed to capture the right atrium at lower rates, but caused a 1:1 capture at higher rates. In an echocardiographic study in another series of eight patients, the end-diastolic diameter of the left atrium was decreased from 3.2 +/- 0.9 to 2.7 +/- 0.8 cm (P less than 0.01) when the pacing rate was increased from 60-70 beats/min to 100-120 beats/min. In experiments using two anesthetized, open-chest dogs, a rapid withdrawal of 500 mL of arterial blood reduced the right atrial dimension. This was accompanied by an increased amplitude of the right atrial endocardial electrogram, and the initially subthreshold stimuli became effective in capturing the atria. It was concluded that (1) rate-dependent threshold changes were commonly observed in the early stage of atrial pacing, and (2) fluctuations in the electrode contact with the endocardium appeared responsible for such threshold changes.