Risk of heart failure- and cardiac death gradually increases with more right ventricular pacing

•Right ventricular pacing is associated with heart failure and cardiac death.•The observed association is linear over the whole range of pacing percentages.•We observed a constant increase of 8% risk of HF death per 10% increase in RVP.

BackgroundRight 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.ObjectiveWe 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.MethodsCumulative 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.ResultsDuring 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.ConclusionThis 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.