Real‐World Treatment of Patients With Sinus Node Dysfunction and Heart Failure With Preserved Ejection Fraction

BACKGROUND: Permanent pacemaker (PPM) implantation is recommended in patients with sinus node dysfunction (SND). In patients with coexisting heart failure with preserved ejection fraction (HFpEF), clinicians may be hesitant to treat SND due to concerns about exacerbating heart failure. Little is known about real-world PPM utilization and disease burden in the HFpEF population that has been assumed to benefit from low heart rates. This study aims to characterize the disease burden and PPM utilization in patients with SND+HFpEF versus SND-only in a Medicare population. METHODS: Patients diagnosed with SND were identified in the Medicare administrative claims database and stratified by presence or abscence of prior evidence of HFpEF. Rates of the following clinical outcomes were compared between the cohorts during follow-up: PPM implant, HF hospitalization, atrial fibrillation (AF) hospitalization, second/third-degree AV block or HFrEF, myocardial infarction (MI), ischemic stroke, and all-cause mortality. RESULTS: SND+HFpEF (N = 26,986) patients were older (81.1 vs. 78.5, p < 0.0001) and more likely to be female (63.5% vs. 49.9%, p < 0.0001) than SND-only patients (N = 74,269). Median follow-up time was 884 days (IQR 476-1408). The PPM implant rate during follow-up was lower in the SND+HFpEF population (HR = 0.811, p < 0.0001). The SND+HFpEF population had higher HF and AF hospitalizations (HR = 2.229 and HR = 1.174, both p < 0.0001), and higher incidence of second/third-degree AV block and HFrEF (HR = 1.364 and HR = 1.640, both p < 0.0001) than the SND-only population. CONCLUSIONS: PPM implant rates were lower, and overall disease burden was greater in HFpEF+SND patients compared to SND-only patients. Future work should focus on optimizing treatment pathways for patients with HFpEF and SND.