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Contemporary practice pattern of permanent pacing for conduction disorders in inferior ST-elevation myocardial
Naoki Misumida1, Gbolahan O Ogunbayo1, John Catanzaro2
1Gill Heart and Vascular Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky.
Insights
Permanent pacemakers are infrequently implanted in inferior ST-elevation myocardial infarction (STEMI) patients with high-degree atrioventricular block (HDAVB). Despite potential reversibility, pacemakers are often implanted early for HDAVB following STEMI.
Area of Science:
- Cardiology
- Cardiac Electrophysiology
- Interventional Cardiology
Background:
- Optimal timing for permanent pacemaker implantation after inferior myocardial infarction (MI) with conduction disorders remains unclear.
- Inferior ST-elevation myocardial infarction (STEMI) can lead to sinoatrial node dysfunction (SND) and atrioventricular (AV) conduction disorders.
- Current guidelines lack consensus on pacing strategies for these specific patient cohorts.
Purpose of the Study:
- To analyze contemporary practice patterns for pacemaker implantation in inferior STEMI patients.
- To specifically investigate the timing of permanent pacemaker implantation for AV conduction disorders and SND.
- To evaluate the association between conduction disorders and in-hospital mortality.
Main Methods:
- Retrospective analysis of the National Inpatient Sample database (2010-2014).
- Identification of patients with inferior STEMI and primary conduction disorders: high-degree AV block (HDAVB) and SND.
- Comparison of pacemaker implantation rates and timing between HDAVB and SND groups.
Main Results:
- Of 66,961 inferior STEMI patients, 4.0% had HDAVB and 0.6% had SND.
- Only 9.9% of HDAVB patients received a permanent pacemaker; over one-third were implanted within 72 hours.
- Median implantation time was 3 days for HDAVB versus 4 days for SND (P < .001); HDAVB increased mortality.
- Sinoatrial node dysfunction (SND) was not associated with increased in-hospital mortality.
Conclusions:
- Permanent pacemaker implantation is uncommon in inferior STEMI patients with high-degree AV block (HDAVB).
- Pacemakers are frequently implanted early, despite the potentially reversible nature of conduction disturbances.
- Further research is needed to establish optimal pacing guidelines for these patients.
Background:
Currently, there is no clear consensus regarding the optimal waiting period before permanent pacemaker implantation in patients with conduction disorders following an inferior myocardial infarction.
Hypothesis:
We aimed to elucidate the contemporary practice pattern of pacing, especially the timing of pacemaker implantation, for sinoatrial node and atrioventricular (AV) conduction disorders following an inferior ST-elevation myocardial infarction (STEMI).
Methods:
Using the National Inpatient Sample database from 2010 to 2014, we identified patients with a primary diagnosis of inferior STEMI. Primary conduction disorders were classified into: (a) high-degree AV block (HDAVB) consisting of complete AV block or Mobitz-type II second-degree AV block, (b) sinoatrial node dysfunction (SND), and (c) no major conduction disorders.
Results:
Among 66 961 patients, 2706 patients (4.0%) had HDAVB, which mostly consisted of complete AV block (2594 patients). SND was observed in 393 patients (0.6%). Among the 2706 patients with HDAVB, 267 patients (9.9%) underwent permanent pacemaker. In patients with HDAVB, more than one-third (34.9%) of permanent pacemakers were placed within 72 hours after admission. The median interval from admission to permanent pacemaker implantation was 3 days (interquartile range; 2-5 days) for HDAVB vs 4 days (3-6 days) for SND (P < .001). HDAVB was associated with increased in-hospital mortality, whereas SND was not.
Conclusions:
In patients who developed HDAVB following an inferior STEMI, only one in 10 patients underwent permanent pacemaker implantation. Despite its highly reversible nature, permanent pacemakers were implanted relatively early.
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