Sex Differences and Long-Term Outcome in Patients With Pacemakers

Abstract

Introduction: Evidence of sex-related differences in patients with pacemakers regarding comorbidities is insufficiently investigated. The aim of this study was to determine the relationship of cardiovascular comorbidities and sex category with properties of pacemaker implantation, pacemaker follow-up, and long-term survival. Methods: This retrospective, single-center cohort study consisted of 6,362 pacemaker-patients (39.7% female) enrolled between May 2000 and April 2015. Functional pacemaker parameters were registered at regular pacemaker controls. Survival status and cause of death were analyzed in relation to comorbidities, implanted pacing devices, and echocardiography. Survival analyses were plotted for a 10-year follow-up. Results: Patients with hypertension or hyperlipidemia had higher rates of implantations due to sick sinus syndrome (28.6 vs. 25.5% without hypertension, P < 0.001; 30.7 vs. 25.7% without hyperlipidemia, P < 0.001), while endocarditis was associated with higher rates of implantations due to AV block (46.7 vs. 33.4%, P < 0.001). Patients with valvular heart disease had higher rates of pacemaker implantation due to bradycardic atrial fibrillation (24.9 vs. 21.0% without valvular heart disease, P < 0.001). Ventricular pacing threshold increased in both sexes during the follow-up and was higher in women in the final follow-up (0.94 vs. 0.91 V in men, P = 0.002). During the 10-years follow-up, 6.1% of women and 8.6% of men underwent lead replacement (P = 0.054). Device and lead replacement rates were increased if the comorbidities coronary artery disease, heart failure, hypertension, hyperlipidemia, valvular heart disease, previous stroke/TIA, atrial arrhythmias, chronic kidney disease, or endocarditis were present. Diabetes and previous CABG increase the rates of device replacement, but not the rate of lead replacement. Severe tricuspid regurgitation after implantation of pacemaker was present in more men than women (14.4 vs. 6.1%, P < 0.001). In a multivariate COX regression, the following variables were associated with independent decrease of 10-year survival: hypertension (HR 1.34, 95% CI 1.09-1.64), chronic kidney disease (HR 1.83, 95% CI 1.53-2.19), tricuspid regurgitation after pacemaker implantation (HR 1.48, 95% CI 1.26-1.74). Survival was independently increased in female sex (HR 0.83, 95% CI 0.70-0.99) and hyperlipidemia (HR 0.81, 95% CI 0.67-0.97). Conclusions: Cardiovascular comorbidities influenced significantly pacemaker implantations and long-term outcome. Trial Registration: ClinicalTrials.gov Unique identifier: NCT03388281.

Keywords: brady arrhythmia; comorbidities; outcome; pacemaker (PM); survival.

Copyright © 2020 Riesenhuber, Spannbauer, Rauscha, Schmidinger, Boszotta, Pezawas, Schukro, Gwechenberger, Stix, Anvari, Wrba, Khazen, Andreas, Laufer, Hengstenberg and Gyöngyösi.

Figures

Figure 1

Baseline parameters (age and indication of device implantation) of patients receiving pacemaker. (A) Age distribution of women and men at the time of first PM implantation. (B) Sex differences in PM implantation. (C) Median first implantation age (99% confidence interval) for patients with different implantation indications. *indicates P < 0.01. AV block, atrioventricular block; BBB, bundle branch block; brady. AF, bradycardic atrial fibrillation; SSS, sick sinus syndrome.

Figure 2

Survival and cause of death in patients with pacemaker. (A) Cause of death including period from 2000 to 2015. (B) Survival in the selected 10-years follow-up after first PM implantation. (C) Cumulative survival in women and men with pacemaker displayed in total patient age. Follow-up of patients with a maximum age of up to 105 years was possible. Source of our survival analysis were data from the Austrian Federal Institute “Statistics Austria,” and 100% of enrolled patients had a complete match with the dataset of “Statistics Austria”.

Figure 3

Outcome in single- and dual-chamber pacemakers. (A) 10-year survival after first PM implantation for single- and dual-chamber PMs; P = 0.003 for comparison of women and men with dual-chamber PMs; P = 0.038 for the comparison of women and men with single-chamber PMs. (B) Cumulative incidence of device or lead replacements in a 10-year follow-up. (C) Cumulative incidence of lead replacements for single- and dual-chamber PMs in a 10-year follow-up. Kaplan–Meier plots show the number of events censored and number of remaining cases at years 0, 2, 4, 6, 8, and 10.