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Permanent Pacemaker Placement in Chronic Atrial Fibrillation Associated with Intermittent AV Block and Cerebral Symptoms
Author(s) -
SAXON LESLIE A.,
ALBERT BRIAN H.,
URETZ EUGENE F.,
DENES PABLO
Publication year - 1990
Publication title -
pacing and clinical electrophysiology
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.686
H-Index - 101
eISSN - 1540-8159
pISSN - 0147-8389
DOI - 10.1111/j.1540-8159.1990.tb02098.x
Subject(s) - medicine , asymptomatic , atrial fibrillation , holter monitor , cardiology , ambulatory , anesthesia , electrocardiography
We examined the hypothesis that a ≥2 second pause detected on 24‐hour Holter monitoring in patients with persistent atrial fibrillation and complaints of syncope or dizziness lacked sufficient specificity to warrant implantation of a permanent pacemaker. We retrospectively reviewed cases from our 24‐hour electrocardiographic (Holter) monitoring data base. A total of 411 consecutive Holter monitoring records demonstrating persistent atrial jibrillation obtained during a 5‐year period (1982 to 1987) were examined. One hundred and five (26%) patients had cerebral symptoms (dizziness or syncope) as a primary indication for monitoring 80 (76%) patients were identified with documented ventricular pauses of ≥2 seconds. Three hundred and six patients (74%) underwent 24‐hour monitoring without cerebral symptoms as an indication and 209 (68%) patients had ≥2‐second pauses. Clinical information was available in 164 (50 symptomatic and 114 asymptomatic) patients. There were no significant differences in the clinical or Holter findings between the two groups. Of the 50 symptomatic patients, 15 (30%) underwent permanent pacemaker placement and the remaining 35 (70%) were managed conservatively during a mean follow‐up of 23 ± 5 months. Eleven of 15 paced (73%) and 31 of 35 (89%) nonpaced patients experienced resolution of their cerebral symptoms (NS). The sensitivity of Holter monitoring in detecting pauses of ≥2 seconds in patients with cerebral symptoms was high (76%), but the specificity (32%) and positive predictive values (28%) were low. In conclusion, the finding of a 2‐second pause interval on Holter monitoring lacks sufficient specificity to identify symptomatic patients with persistent atrial fibrillation. In addition, there is a high rate of spontaneous resolution of cerebral symptoms in this group without the use of a pacemaker. These findings suggest that in patients with persistent atrial fibrillation in the presence of a 2‐second pause on a Holter recording, a clear association between cerebral symptom and the pause interval is necessary before the use of a permanent pacemaker is recommended.