title: Risk of heart failure- and cardiac death gradually increases with more right ventricular pacing.
abstract: BACKGROUND
  Right ventricular pacing (RVP) is associated with an increased risk of heart failure (HF) events. However, the extent and shape of this association is hardly assessed.
  
  
  OBJECTIVE
  We quantified whether the undesired effects of RVP are confirmed in an unselected population of first bradycardia pacemaker recipients. Furthermore, we studied the shape of the association between RVP and HF death and cardiac death.
  
  
  METHODS
  Cumulative percentage RVP (%RVP) was measured in 1395 patients. Using multivariable Cox regression analysis with %RVP as time-dependant co-variate we evaluated the association between %RVP and HF- and cardiac death, both unadjusted and adjusted for confounders, including age, gender, pacemaker-indication, cardiac disease, HF at baseline, diabetes, hypertension, atrio-ventricular synchrony, usage of beta-blocking drugs, anti-arrhythmic medication, HF medication, and prior atrial fibrillation/flutter. Non-linear associations were evaluated with restricted cubic splines.
  
  
  RESULTS
  During a mean follow-up of 5.8 (SD 1.1) years 104 HF deaths and 144 cardiac deaths were observed. %RVP was significantly associated with HF- and cardiac death in both unadjusted (p<0.001 and p<0.001, respectively) and adjusted analyses (p=0.046 and p=0.009, respectively). Our results show a linear association between %RVP and HF- and cardiac death. We observed a constant increase of 8% risk of HF death per 10% increase in RVP. A model incorporating various non-linear transformations of %RVP using restrictive cubic splines showed no improved model fit over linear associations.
  
  
  CONCLUSIONS
  This long-term, prospective study observed a significant, though linear association between %RVP and risk of HF death and/or cardiac death in unselected bradycardia pacing recipients.
authors: Department of Cardiology, UMC Utrecht, The Netherlands, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, UMC Utrecht, The Netherlands, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands. Electronic address: e.o.udo@umcutrecht.nl.
authors: Erik O
authors: EO
authors: Udo
authors: Department of Cardiology, UMC Utrecht, The Netherlands, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
authors: Norbert M
authors: NM
authors: van Hemel
authors: Julius Center for Health Sciences and Primary Care, UMC Utrecht, The Netherlands, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands.
authors: Nicolaas P A
authors: NP
authors: Zuithoff
authors: Department of Cardiology, UMC Utrecht, The Netherlands, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
authors: Pieter A
authors: PA
authors: Doevendans
authors: Julius Center for Health Sciences and Primary Care, UMC Utrecht, The Netherlands, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands.
authors: Karel G M
authors: KG
authors: Moons
mesh_terms: D000368:Aged; D001145:Arrhythmias, Cardiac / Q000401:mortality*; D001919:Bradycardia / Q000628:therapy; D002304:Cardiac Pacing, Artificial; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000401:mortality*; D006801:Humans; D016014:Linear Models; D008297:Male; D009203:Myocardial Infarction / Q000401:mortality*; D009426:Netherlands / Q000453:epidemiology; D010138:Pacemaker, Artificial; D011446:Prospective Studies; D018497:Ventricular Dysfunction, Right / Q000628:therapy
keywords: Heart failure; Pacemaker; Survival