{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,10]],"date-time":"2026-08-10T01:46:04Z","timestamp":1786326364663,"version":"build-2736575974"},"reference-count":120,"publisher":"National Institute for Health and Care Research","issue":"65","license":[{"start":{"date-parts":[[2015,8,1]],"date-time":"2015-08-01T00:00:00Z","timestamp":1438387200000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/www.nationalarchives.gov.uk\/doc\/non-commercial-government-licence\/non-commercial-government-licence.htm"}],"funder":[{"DOI":"10.13039\/501100000664","name":"Health Technology Assessment programme","doi-asserted-by":"publisher","award":["13\/48\/01"],"award-info":[{"award-number":["13\/48\/01"]}],"id":[{"id":"10.13039\/501100000664","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Health Technol Assess"],"abstract":"<jats:sec id=\"abs1-1\"><jats:title>Background<\/jats:title><jats:p>Bradycardia [resting heart rate below 60\u2009beats per minute (b.p.m.)] can be caused by conditions affecting the natural pacemakers of the heart, such as sick sinus syndrome (SSS) and atrioventricular (AV) blocks. People suffering from bradycardia may present with palpitations, exercise intolerance and fainting. The only effective treatment for patients suffering from symptomatic bradycardia is implantation of a permanent pacemaker.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-2\"><jats:title>Objective<\/jats:title><jats:p>To appraise the clinical effectiveness and cost-effectiveness of dual-chamber pacemakers compared with single-chamber atrial pacemakers for treating symptomatic bradycardia in people with SSS and no evidence of AV block.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-3\"><jats:title>Data sources<\/jats:title><jats:p>All databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Health Technology Assessment database, NHS Economic Evaluations Database) were searched from inception to June 2014.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-4\"><jats:title>Methods<\/jats:title><jats:p>A systematic review of the clinical and economic literature was carried out in accordance with the general principles published by the Centre for Reviews and Dissemination. Randomised controlled trials (RCTs) evaluating dual-chamber and single-chamber atrial pacemakers and economic evaluations were included. Pairwise meta-analysis was carried out. A de novo economic model was developed.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-5\"><jats:title>Results<\/jats:title><jats:p>Of 493 references, six RCTs were included in the review. The results were predominantly influenced by the largest trial DANPACE. Dual-chamber pacing was associated with a statistically significant reduction in reoperation [odds ratio (OR) 0.48, 95% confidence interval (CI) 0.36 to 0.63] compared with single-chamber atrial pacing. The difference is primarily because of the development of AV block requiring upgrade to a dual-chamber device. The risk of paroxysmal atrial fibrillation was also reduced with dual-chamber pacing compared with single-chamber atrial pacing (OR 0.75, 95% CI 0.59 to 0.96). No statistically significant difference was found between the pacing modes for mortality, heart failure, stroke, chronic atrial fibrillation or quality of life. However, the risk of developing heart failure may vary with age and device. The de novo economic model shows that dual-chamber pacemakers are more expensive and more effective than single-chamber atrial devices, resulting in a base-case incremental cost-effectiveness ratio (ICER) of \u00a36506. The ICER remains below \u00a320,000 in probabilistic sensitivity analysis, structural sensitivity analysis and most scenario analyses and one-way sensitivity analyses. The risk of heart failure may have an impact on the decision to use dual-chamber or single-chamber atrial pacemakers. Results from an analysis based on age (&gt;\u200975 years or \u2264\u200975 years) and risk of heart failure indicate that dual-chamber pacemakers dominate single-chamber atrial pacemakers (i.e. are less expensive and more effective) in older patients, whereas dual-chamber pacemakers are dominated by (i.e. more expensive and less effective) single-chamber atrial pacemakers in younger patients. However, these results are based on a subgroup analysis and should be treated with caution.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-6\"><jats:title>Conclusions<\/jats:title><jats:p>In patients with SSS without evidence of impaired AV conduction, dual-chamber pacemakers appear to be cost-effective compared with single-chamber atrial pacemakers. The risk of developing a complete AV block and the lack of tools to identify patients at high risk of developing the condition argue for the implantation of a dual-chamber pacemaker programmed to minimise unnecessary ventricular pacing. However, considerations have to be made around the risk of developing heart failure, which may depend on age and device.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-7\"><jats:title>Study registration<\/jats:title><jats:p>This study is registered as PROSPERO CRD42013006708.<\/jats:p><\/jats:sec><jats:sec id=\"abs1-8\"><jats:title>Funding<\/jats:title><jats:p>The National Institute for Health Research Health Technology Assessment programme.<\/jats:p><\/jats:sec>","DOI":"10.3310\/hta19650","type":"journal-article","created":{"date-parts":[[2015,8,25]],"date-time":"2015-08-25T07:55:48Z","timestamp":1440489348000},"page":"1-210","update-policy":"https:\/\/doi.org\/10.3310\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":11,"title":["Dual-chamber pacemakers for treating symptomatic bradycardia due to sick sinus syndrome without atrioventricular block: a systematic review and economic evaluation"],"prefix":"10.3310","volume":"19","author":[{"given":"Steven J","family":"Edwards","sequence":"first","affiliation":[{"name":"BMJ Technology Assessment Group, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Charlotta","family":"Karner","sequence":"additional","affiliation":[{"name":"BMJ Technology Assessment Group, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicola","family":"Trevor","sequence":"additional","affiliation":[{"name":"BMJ Technology Assessment Group, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Victoria","family":"Wakefield","sequence":"additional","affiliation":[{"name":"BMJ Technology Assessment Group, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fatima","family":"Salih","sequence":"additional","affiliation":[{"name":"BMJ Technology Assessment Group, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"6221","published-online":{"date-parts":[[2015,8]]},"reference":[{"key":"key20150810150105398_ref1-bib1","doi-asserted-by":"publisher","first-page":"1921","DOI":"10.1161\/CIRCULATIONAHA.106.616011","article-title":"New insights into pacemaker activity: promoting understanding of sick sinus syndrome","volume":"115","author":"Dobrzynski","year":"2007","journal-title":"Circulation"},{"key":"key20150810150105398_ref1-bib2","first-page":"691","article-title":"Sick sinus syndrome: a review","volume":"87","author":"Semelka","year":"2013","journal-title":"Am Fam Physician"},{"key":"key20150810150105398_ref1-bib3","doi-asserted-by":"publisher","first-page":"635","DOI":"10.1161\/01.CIR.47.3.635","article-title":"The sick sinus syndrome","volume":"47","author":"Ferrer","year":"1973","journal-title":"Circulation"},{"key":"key20150810150105398_ref1-bib4","doi-asserted-by":"publisher","first-page":"e1","DOI":"10.1016\/j.jacc.2008.02.032","article-title":"ACC\/AHA\/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology\/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC\/AHA\/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons","volume":"51","author":"Epstein","year":"2008","journal-title":"J Am Coll Cardiol"},{"key":"key20150810150105398_ref1-bib5","doi-asserted-by":"publisher","first-page":"1010","DOI":"10.1161\/CIRCULATIONAHA.110.940577","article-title":"Chronotropic incompetence: causes, consequences, and management","volume":"123","author":"Brubaker","year":"2011","journal-title":"Circulation"},{"key":"key20150810150105398_ref1-bib6","doi-asserted-by":"publisher","first-page":"636","DOI":"10.1136\/hrt.40.6.636","article-title":"Prevalence and prognosis of electrocardiographic findings in middle-aged men","volume":"40","author":"Rose","year":"1978","journal-title":"Br Heart J"},{"key":"key20150810150105398_ref1-bib7","doi-asserted-by":"publisher","first-page":"2281","DOI":"10.1093\/eurheartj\/eht150","article-title":"ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: the Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). 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