what are the differnt ways to determine the seconds for sinus pause
Clinical Perspective
What Is New?
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In our study, patients with pauses 2 to 3 seconds in length (intermediate pauses) occurring during the day or dark increased the run a risk of adverse cardiovascular events (including all‐crusade hospitalization, cardiovascular hospitalization, pacemaker implantation, new‐onset atrial fibrillation, new‐onset heart failure, and transient ischemic attack) compared with patients without pauses.
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Intermediate pauses occurring during the day, either alone or in combination with intermediate pauses at nighttime, were associated with increased bloodshed rate compared with pauses present that solely occurred at night; this was especially notable in those with a sick sinus syndrome pause pattern and a high frequency of pauses.
What Are the Clinical Implications?
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In daily clinical practise, physicians should pay attending to patients with intermediate pause and intensively follow them for the development of atrial fibrillation and heart failure.
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Early and adequate treatment of underlying comorbidities might help to reduce future cardiovascular take chances in intermediate pause patients.
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An electrophysiology written report might be considered to uncover sinus or atrioventricular nodal dysfunction in patients with intermediate pauses who present with presyncope or syncope.
Introduction
Symptomatic bradycardia is the virtually mutual indication for permanent pacemaker implantation, which tin event in cerebral hypoperfusion and subsequent syncope.1 In symptomatic patients with a ventricular pause of more than iii seconds, the European Social club of Cardiology and American Heart Association guidelines recommend pacemaker implantation in these patients to prevent further adverse events, except for patients who were asleep or on medication.i However, the current 3‐second criterion is an arbitrary clinical ascertainment with a low specificity.3 Most patients with intermediate pauses (2–iii seconds in duration) are asymptomatic and non candidates for pacemaker implantation past current applied guidelines.i All the same, some patients with intermediate pauses (ie, sinus suspension of 2–3 seconds in duration) did develop syncope that somewhen leads to pacemaker implantation.ane There were no long‐term follow‐upwardly data regarding patients with intermediate pauses and future cardiovascular events and mortality. Whether these asymptomatic patients with intermediate pauses have a benign clinical course for time to come cardiovascular events remains unclear.
In this study, using the 24‐hour Holter monitoring database in a patient population that was followed upwards for 8 years, we will be able to explore the long‐term risk of cardiovascular events and bloodshed in patients with intermediate pauses. Pauses at nighttime take been considered to be a physiological rather than pathological response attributed to autonomic regulation and might spare intensive intervention. Therefore, intermediate pauses occurring at daytime or dark may have a dissimilar impact on cardiovascular risks. Furthermore, the patterns (ie, atrioventricular block [AVB] or sinus arrest) and frequency of these intermediate pauses might too differently contribute to cardiovascular events with respect to their occurring time. Nosotros hypothesize that intermediate pauses occurring at daytime is associated with higher cardiovascular risk and mortality rate than those at nighttime.
Methods
This study was approved by the Institutional Review Lath at Taipei Veterans General Hospital, Taipei, Taiwan (VGH‐IRB Number: 2013‐08‐002AC#1). Because the patient records/information was anonymous and de‐identified before analysis, there was no need for obtaining patients' informed consent. The data, analytical methods, and study materials will not be made available to other researchers for purposes of reproducing the results or replicating the procedure because this was not function of our original Institutional Review Board approval.
Study Population
This retrospective, observational report was performed past analyzing the "Registry of 24‐hour ECG monitoring at Taipei Veterans General Hospital" database. Taipei Veterans General Hospital is a large integrated healthcare delivery system and provides comprehensive medical services to more than than 3 million people in Taiwan. The study database included 5903 consecutive patients who were anile >18 years and who underwent clinically indicated 24‐hour Holter monitoring between Jan 1, 2002 and December 31, 2004. Indications for Holter monitoring were palpitation, syncope, suspected arrhythmia, and clinical follow‐upward past the physicians' discretion. Clinical variables, including past medical histories, gamble factors, comorbidities, and medications, were obtained from the medical records of the primary/secondary referral hospitals, outpatient visits, emergency visits, the Collaboration Center of Wellness Information Application (CCHIA), and the Ministry building of Health and Welfare in Taiwan. The International Nomenclature of Diseases ‐ Ninth Revision (ICD‐9) codes were also used for identifying underlying diseases, including diabetes mellitus, hypertension, coronary artery disease, centre failure, chronic kidney disease, liver disease, myocardial infarction, and valvular centre affliction. The New York Center Association functional classifications of patients were adamant from the medical and nursing records.
Clinical diagnoses of interests were confirmed to be valid only if they have been recorded at least twice in outpatient records or once in hospitalization records. Patients were excluded if they have atrial palpitate/AF, high‐degree AVB, symptomatic bradycardia, or the longest R‐R interval is ≥iii seconds by the 12‐lead ECG or 24‐hour Holter monitoring. Patients were also excluded if they had a pacemaker implanted before this study or had a history of catheter ablation for arrhythmia. After excluding the above‐mentioned patients, the concluding sample size was 5291 patients.
Cardiovascular Outcomes
The principal outcome in this study is mortality. Secondary outcomes include hospitalization for whatsoever reason (all‐crusade hospitalization), hospitalization for cardiovascular causes, the occurrence of new‐onset AF, new‐onset middle failure (HF), permanent pacemaker (PPM) implantation, transient ischemic attack (TIA) and ischemic stroke. Patients taking regular medication were regularly followed up at an interval of one to 3 months. Those with a new cardiovascular effect were followed upwards every ii weeks for the first calendar month and at an interval of 1 to 3 months thereafter. Patients who did non take regular medication were followed up annually or at the discretion of the physicians. Medical records retrieved from the Taipei Veterans General Infirmary were used for effect survey equally in our previous study.eight New cardiovascular events, inpatient admissions, and deaths were identified through the ICD diagnostic codes, mention of an end betoken on the face sheet of the medical record, previous discharge summary, and outpatient clinic reports. Mortality was divers equally passing abroad during hospitalization or discharge under critical status. Hospitalization was defined as an overnight stay in a hospital ward, excluding emergency department visit. New‐onset HF and AF were identified by physician written report, echocardiography data, ECG tracing, and mention of the events in the medical tape. The observation menstruation was from the date of patient registration until February 28, 2013. Multivariate analysis with the Cox hazards regression model was used to assess the chance ratio (HR) for mortality (master event) and adverse cardiovascular events (secondary consequence).
Patient Groups and Definition of Pauses
The 24‐hr Holter monitoring data were reviewed by electrophysiological experts equally in our previous work.viii Patients with intermediate pauses (the longest R‐R interval of ≥ii and <3 seconds) constituted the study grouping. Intermediate break patients whose intermission occurred solely at daytime (8:00 am–8:00 pm) were classified into the daytime break (DTP) grouping, whereas those whose intermission occurred only at night (8:00 pm–8:00 am) were the nighttime suspension (NTP) group. Patients whose intermediate pause occurred at both daytime and night constituted the daytime plus nighttime break (DNTP) group. Control grouping patients were those whose R‐R interval was <two seconds in elapsing and constituted the no pause (NOP) group.
Patterns of intermediate pauses were classified into ill sinus (ISS), AVB (intermediate pause of atrioventricular block pattern), and combined (both ISS and intermediate pause of atrioventricular block pattern) patterns. The ISS design was divers equally sinus abort, sinus exit cake, or sinus pause proceeded past an atrial/ventricular premature contraction, whereas the intermediate pause of atrioventricular block pattern was intermediate pauses caused by Mobitz type one second‐degree AVB. Frequency of intermediate pauses was divided into high and low frequencies. High‐frequency patients were those whose pause occurrence frequency was equal or higher than the median frequency in each group. The residue of the patients in each group constituted the depression‐frequency patients.
Statistical Analysis
Statistical analyses were performed by SPSS statistical software (version twenty.0; SPSS, Inc., Chicago, IL). Patient characteristics are expressed as mean±SD for continuous variables and percentages for categorical variables. Continuous and categorical variables were compared using the Student t exam and Pearson's chi‐square test with Yates' correction, respectively. An alpha error of less than 5% was considered statistically pregnant. Kaplan–Meier survival curves with log‐rank tests were used to analyze survival information (fourth dimension to adverse event). A Cox regression hazards model was applied to estimate the HR of the fourth dimension to adverse events.
Results
Baseline Characteristics
A total of 5291 patients were enrolled in this report: 4859 (91.8%) were in the NOP (control) group, whereas 248 (4.7%), 103 (one.ix%), and 81 (1.five%) patients were in the NTP, DTP, and DNTP groups, respectively. Table 1 shows the baseline characteristics of the patients. Patients in the NTP, DTP and DNTP groups were older (P<0.001), had a higher percentage of male patients (P<0.001), and with a higher incidence of hypertension (P<0.001) compared with the NOP group. The incidence of coronary artery disease in the DTP grouping (26.2%) was lower than that of the NOP (28.9%), NTP (37.1%), and DNTP (32.1%) groups (P=0.039). Therefore, the pct of patients who used cardiovascular medications were lower in the DTP group (seven.8%) than the other groups (P=0.020). At that place was no statistical difference among these 4 groups of patients on baseline ECG characteristics, including first‐degree AVB (P=0.228), Mobitz type I AVB (P=0.405), left bundle branch block (P=0.501), and right parcel branch block (P=0.366).
| Baseline Characteristics | NOP (N=4859) | NTP (N=248) | DTP (N=103) | DNTP (N=81) | P Value |
|---|---|---|---|---|---|
| Age, y | 60.9±eighteen.6 | 69.5±17.ii | 69.1±16.three | 71.0±thirteen.4 | <0.001 |
| Men, n (%) | 2844 (58.five) | 184 (74.2) | 72 (69.9) | 62 (76.v) | <0.001 |
| Previous MI, n (%) | 27 (0.6) | ii (0.8) | 0 (0.0) | 1 (1.2) | 0.684 |
| Valvular heart affliction, northward (%) | 95 (2.0) | vii (2.viii) | ane (1.0) | 0 (0.0) | 0.373 |
| Hypothyroidism, n (%) | 23 (0.v) | ii (0.8) | 0 (0.0) | one (1.2) | 0.581 |
| Malignancy, n (%) | 142 (2.9) | 6 (2.iv) | seven (6.8) | 4 (4.9) | 0.089 |
| Cirrhosis, due north (%) | 25 (0.five) | 0 (0.0) | 1 (1.0) | 1 (ane.2) | 0.468 |
| Cardiovascular risk factors | |||||
| Diabetes mellitus, n (%) | 464 (9.5) | 30 (12.1) | 11 (ten.7) | 12 (14.8) | 0.238 |
| Hypertension, n (%) | 1666 (34.three) | 114 (46.0) | 43 (41.vii) | 46 (56.8) | <0.001 |
| Dyslipidemia, n (%) | 180 (3.7) | 11 (4.4) | two (1.nine) | v (half-dozen.ii) | 0.457 |
| Heart failure, north (%) | 229 (four.7) | thirteen (five.2) | 3 (2.nine) | 0 (0.0) | 0.179 |
| LVEF, % | 64.0±5.3 | 64.two±4.1 | 64.2±4.five | 64.7±1.2 | 0.664 |
| NYHA Fc I, n (%) | 119 (2.4) | 10 (iv.0) | 3 (2.ix) | 0 (0.0) | 0.204 |
| NYHA Fc II, n (%) | 55 (1.one) | 1 (0.4) | 1 (i.0) | 0 (0.0) | 0.555 |
| NYHA Fc III, n (%) | 53 (ane.ane) | 2 (0.8) | 1 (ane.0) | 0 (0.0) | 0.784 |
| NYHA Fc IV, n (%) | two (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0.981 |
| CAD, n (%) | 1406 (28.9) | 92 (37.i) | 27 (26.2) | 26 (32.1) | 0.039 |
| CKD, n (%) | 50 (1.0) | 2 (0.8) | ii (ane.ix) | two (two.five) | 0.476 |
| Medication, north (%) | 921 (19.0) | 39 (fifteen.seven) | eight (7.eight) | 16 (xix.8) | 0.020 |
| Antiarrhythmia a | 34 (0.7) | ii (0.8) | 0 (0.0) | 2 (ii.v) | 0.233 |
| Antihypertensives | 895 (18.4) | 38 (15.three) | 8 (seven.viii) | fifteen (xviii.5) | 0.028 |
| Beta‐blocker | 135 (2.8) | 5 (2.0) | 3 (2.9) | 0 (0.0) | 0.421 |
| Dihydropyrimidine CCB | 388 (8.0) | 14 (five.6) | 5 (4.9) | 6 (seven.4) | 0.378 |
| Nondihydropyrimidine CCB | 187 (three.8) | x (4.0) | 1 (1.0) | 2 (2.5) | 0.436 |
| ACEI/ARB | 246 (5.i) | 9 (three.half-dozen) | v (4.9) | 6 (vii.4) | 0.573 |
| Diuretics | 370 (7.half-dozen) | 16 (six.5) | 4 (3.nine) | 7 (8.6) | 0.461 |
| Alpha‐blocker | 53 (1.1) | 1 (0.4) | 0 (0.0) | 3 (3.vii) | 0.059 |
| Statins | 173 (3.six) | 10 (four.0) | 2 (1.9) | 5 (6.2) | 0.471 |
| ECG parameters | |||||
| First‐degree atrioventricular block | 405 (8.3%) | 26 (10.v%) | xiii (12.6%) | 9 (11.i%) | 0.228 |
| Mobitz type I atrioventricular block | 91 (one.9%) | seven (2.8%) | 3 (2.9%) | 3 (3.seven%) | 0.405 |
| LBBB | 32 (0.seven%) | 3 (1.two%) | 0 (0.0%) | 0 (0.0%) | 0.501 |
| RBBB | 341 (seven.0%) | 23 (9.3%) | 9 (eight.7%) | eight (nine.nine%) | 0.366 |
Intermediate Suspension and Cardiovascular Outcomes
During the follow‐up period of 8.viii±1.7 years, a total of 343 (6.5%) patients died. In the 5291 patients, 3061 (57.9%) were hospitalized for any reasons, 1129 (21.3%) were hospitalized for cardiovascular causes, 108 (2.0%) had PPM implantation, 399 (7.5%) adult new‐onset AF, 524 (9.9%) had new‐onset HF, 493 (9.iii%) had TIA, and 480 (9.1%) had ischemic stroke episodes.
Tabular array 2 shows the blended cardiovascular outcomes during the follow‐upward period. Comparing with the NOP group, NTP patients showed a college rate of the composite cardiovascular events, including all‐cause of hospitalization (60 minutes, 1.19; P=0.030), cardiovascular‐crusade hospitalization (HR, 1.83; P<0.001), PPM implantation (HR, 4.28; P<0.001), new‐onset of AF (HR, 2.13; P<0.001), new‐onset of HF (HR, i.63; P=0.001), and TIA (Hour, 2.52; P<0.001; Table two ). Similarly, DTP and DNTP patients had a higher rate of blended cardiovascular events, including all‐cause hospitalization (DTP versus NOP: 60 minutes, 1.28, P=0.039; DNTP versus NOP: HR, 1.47, P=0.003), cardiovascular‐crusade hospitalization (HR, i.71, P=0.003; Hour, 2.15, P<0.001, respectively), PPM implantation (HR, iii.97, P=0.001; 60 minutes, ten.92, P<0.001, respectively), new‐onset AF (HR, ane.90, P=0.020; 60 minutes, 2.72, P<0.001, respectively), new‐onset HF (60 minutes, 1.70, P=0.025; HR, 1.seventy, P=0.028, respectively), and TIA (60 minutes, two.08, P=0.003; 60 minutes, ii.98, P<0.001, respectively) than those of NOP patients (Tables 2 and 3 ). The above‐mentioned cardiovascular event rates were similar amidst NTP, DTP and DNTP patients, except for PPM implantation rates. PPM implantation rate was higher in the DNTP than that in the NTP (Hr, two.48; P=0.010; Table 2 ) and DTP (60 minutes, ii.64; P=0.041) groups (Table 3 ). Ischemic stroke rate was indifferent amongst the 4 groups of patients (P=ns for any 2 of the 4 groups; Table ii ).
| NOP | NTP | DTP | DNTP | NTP vs NOP a | DTP vs NOP a | DTP vs NTP a | DNTP vs NTP a | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| N=4859 | N=248 | North=103 | Northward=81 | Hour (95% CI) | P Value | HR (95% CI) | P Value | HR (95% CI) | P Value | 60 minutes (95% CI) | P Value | |
| All‐cause hospitalization, northward (%) | 2756 (56.vii) | 171 (69.0) | 73 (70.9) | 61 (75.3) | 1.19 (1.02–1.39) | 0.030 | i.28 (i.01–1.62) | 0.039 | 1.08 (0.81–ane.42) | 0.611 | 1.22 (0.91–1.64) | 0.191 |
| Cardiovascular‐cause hospitalization, n (%) | 964 (19.eight) | 97 (39.ane) | 33 (32.0) | 35 (43.2) | i.83 (1.48–two.26) | <0.001 | 1.71 (1.21–2.43) | 0.003 | 0.93 (0.62–1.39) | 0.706 | 1.13 (0.77–i.67) | 0.535 |
| PPM implantation, n (%) | 67 (ane.4) | 19 (7.7) | vii (6.8) | 15 (18.5) | 4.28 (2.54–seven.20) | <0.001 | 3.97 (i.80–8.74) | 0.001 | 0.84 (0.35–2.02) | 0.700 | 2.48 (ane.24–4.95) | 0.010 |
| New‐onset AF, n (%) | 329 (half dozen.8) | 39 (15.7) | 14 (xiii.six) | 17 (21.0) | 2.13 (1.52–two.98) | <0.001 | 1.ninety (1.11–3.26) | 0.020 | 0.fourscore (0.43–one.50) | 0.494 | i.29 (0.72–2.30) | 0.389 |
| New‐onset HF, north (%) | 438 (ix.5) | 49 (xx.9) | 19 (nineteen.0) | 18 (22.ii) | 1.63 (one.21–two.twenty) | 0.001 | 1.70 (ane.07–2.seventy) | 0.025 | 0.92 (0.53–1.58) | 0.749 | one.05 (0.61–ane.81) | 0.857 |
| TIA, due north (%) | 399 (8.two) | 54 (21.eight) | 18 (17.5) | 22 (27.2) | two.52 (1.89–3.36) | <0.001 | 2.08 (1.29–3.35) | 0.003 | 0.76 (0.44–1.31) | 0.317 | ane.23 (0.75–2.04) | 0.414 |
| Ischemic stroke, northward (%) | 433 (8.9) | 27 (10.ix) | 11 (ten.7) | 9 (xi.1) | one.12 (0.75–1.65) | 0.584 | 1.07 (0.59–ane.95) | 0.831 | 0.92 (0.45–ane.88) | 0.822 | one.07 (0.50–two.27) | 0.871 |
| Mortality, due north (%) | 286 (v.ix) | 23 (9.3) | 19 (18.four) | fifteen (xviii.5) | i.00 (0.65–1.54) | 0.997 | ii.26 (one.41–iii.61) | 0.001 | 2.35 (one.25–4.41) | 0.008 | 2.26 (one.xvi–4.xl) | 0.016 |
| Cardiovascular Event | DNTP vs NOP a | DNTP vs DTP a | ||
|---|---|---|---|---|
| HR (95% CI) | P Value | 60 minutes (95% CI) | P Value | |
| All‐cause hospitalization | 1.47 (one.14–i.90) | 0.003 | ane.20 (0.84–1.70) | 0.321 |
| Cardiovascular‐cause hospitalization | 2.fifteen (1.53–3.02) | <0.001 | 1.27 (0.77–2.x) | 0.341 |
| PPM implantation | 10.92 (half dozen.14–nineteen.41) | <0.001 | 2.64 (one.04–6.71) | 0.041 |
| New‐onset AF | 2.72 (ane.66–4.45) | <0.001 | ane.23 (0.58–2.threescore) | 0.585 |
| New‐onset HF | ane.70 (1.06–2.74) | 0.028 | 1.08 (0.54–2.14) | 0.831 |
| TIA | two.98 (1.93–iv.threescore) | <0.001 | 1.34 (0.70–2.57) | 0.376 |
| Ischemic stroke | 1.12 (0.58–2.17) | 0.743 | 1.07 (0.43–2.64) | 0.886 |
| Mortality | 2.04 (1.21–3.44) | 0.008 | 1.04 (0.50–2.17) | 0.910 |
The mortality rate in DTP patients is college than that of the NOP (Hr, 2.26; P=0.001) and NTP (HR, 2.35; P=0.008) patients (Table ii ). DNTP patients also have a higher mortality charge per unit than that of the NTP (60 minutes, 2.26; P=0.016; Tabular array 2 ) and NOP (HR, ii.04; P=0.008; Tabular array 3 ) patients. Mortality rates were similar between NTP and NOP patients (HR, 1.00; P=0.997) and betwixt DNTP and DTP patients (HR, 1.04; P=0.910; Tables 2 and 3 ).
Effigy1 shows Kaplan–Meier survival curves with log‐rank examination in all‐cause hospitalization (FigureaneA; P<0.001), cardiovascular causes of hospitalization (EffigyoneB; P<0.001), PPM implantation (FigureoneC; P<0.001), new‐onset AF (EffigyoneD; P<0.001), new‐onset HF (Figure1E; P<0.001), TIA (FigureiF; P<0.001), ischemic stroke (FigureaneK; P=0.609), and all‐cause bloodshed (Figure1H; P<0.001) among the 4 groups of patients. Log‐rank P values betwixt different groups are shown in Table 4 .
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Effigy 1 Kaplan–Meier survival curves of cardiovascular outcomes and mortality in the four groups of patients. A, All‐cause hospitalization; B, cardiovascular cause of hospitalization; C, permanent pacemaker (
| Kaplan–Meier Curve | NTP vs NOP | DTP vs NOP | DNTP vs NOP | DTP vs NTP | DNTP vs NTP | DNTP vs DTP |
|---|---|---|---|---|---|---|
| Log‐Rank P Value | Log‐Rank P Value | Log‐Rank P Value | Log‐Rank P Value | Log‐Rank P Value | Log‐Rank P Value | |
| All‐cause hospitalization | <0.001 | 0.001 | <0.001 | 0.846 | 0.181 | 0.309 |
| Cardiovascular‐cause hospitalization | <0.001 | 0.001 | <0.001 | 0.223 | 0.476 | 0.106 |
| PPM implantation | <0.001 | <0.001 | <0.001 | 0.780 | 0.005 | 0.015 |
| New‐onset AF | <0.001 | 0.010 | <0.001 | 0.550 | 0.390 | 0.205 |
| New‐onset HF | <0.001 | 0.001 | <0.001 | 0.671 | 0.843 | 0.579 |
| TIA | <0.001 | 0.001 | <0.001 | 0.339 | 0.454 | 0.141 |
| Ischemic stroke | 0.270 | 0.605 | 0.505 | 0.902 | 0.975 | 0.905 |
| Mortality | 0.033 | <0.001 | <0.001 | 0.016 | 0.026 | 0.989 |
Intermediate Interruption Patterns and Frequencies on Mortality
Mortality rates were similar among different patterns within the NTP (P=0.304), DTP (P=0.710), and DNTP (P=0.440) groups (Table v ). Kaplan–Meier survival curves showed no differences in mortality charge per unit amid unlike pause patterns inside the three groups of patients (Figure2). ISS patients in the DNTP groups had a higher mortality rate than that of ISS patients in the NTP groups (Hour, two.37; P=0.032; Table 6 ). Patients presenting with ISS pattern in the DTP (HR, 1.88; P=0.028) and DNTP (HR, 1.94; P=0.032) groups showed a higher mortality rate than that in the NOP group (Table vi ). Compared with the NOP group, DTP patients with intermediate pause of atrioventricular block design likewise have an increased mortality rate (HR, 4.24; P=0.005; Tabular array half dozen ).
| Pause Patterns | NTP (Due north=248) | DTP (Due north=103) | DNTP (N=81) | ||||||
|---|---|---|---|---|---|---|---|---|---|
| N | Death | Mortality (%) | North | Expiry | Mortality (%) | N | Expiry | Mortality (%) | |
| Ill sinus | 189 | 17 | 9.0 | 78 | xiii | 16.7 | 66 | eleven | 16.seven |
| Atrioventricular cake | 44 | 3 | 6.8 | 17 | iv | 23.five | 13 | 3 | 23.1 |
| Combined | 15 | 3 | 20.0 | 8 | two | 25.0 | 2 | 1 | 50.0 |
| P value within group a | 0.304 | 0.710 | 0.440 | ||||||
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Figure 2 Intermediate interruption blueprint on bloodshed rates within the
| Pause Pattern | DTP vs NTP a | DNTP vs NTP a | DNTP vs DTP a | NTP vs NOP a | DTP vs NOP a | DNTP vs NOP a | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| HR (95% CI) | P Value | Hour (95% CI) | P Value | Hr (95% CI) | P Value | HR (95% CI) | P Value | HR (95% CI) | P Value | HR (95% CI) | P Value | |
| Sick sinus | ane.89 (0.88–4.05) | 0.102 | ii.37 (1.08–5.23) | 0.032 b | ane.01 (0.43–ii.twoscore) | 0.982 | i.xi (0.68–1.82) | 0.671 | 1.88 (i.07–3.29) | 0.028 b | ane.94 (1.06–3.54) | 0.032 b |
| Atrioventricular block | four.xi (0.48–35.01) | 0.196 | 2.37 (0.23–24.45) | 0.469 | 2.62 (0.28–24.22) | 0.397 | 1.02 (0.33–3.xix) | 0.972 | 4.24 (1.57–11.49) | 0.005 b | 2.15 (0.69–six.75) | 0.190 |
| Combined | 1.52 (0.84–27.fifty) | 0.778 | 4.42 (0.21–93.53) | 0.340 | 1.12 (0.04–32.15) | 0.948 | 2.89 (0.92–ix.04) | 0.069 | 3.17 (0.79–12.lxxx) | 0.105 | 3.59 (0.l–25.85) | 0.204 |
Median frequencies of the intermediate pauses were 3, 3, and 23 times/solar day in the NTP, DTP, and DNTP patients, respectively (Table 7 ). Bloodshed rates were indifferent between high‐ and depression‐frequency patients within the NTP (P=0.325), DTP (P=0.221), and DNTP (P=0.484) groups (Table 7 ). Kaplan–Meier survival curves showed no deviation in mortality rate between the high‐ and depression‐pause‐frequency patients within the 3 groups of patients (Figure3). High‐pause‐frequency patients in the DTP (HR, 3.42; P=0.006) and DNTP (60 minutes, 1.72; P=0.023) groups had a higher mortality charge per unit than that in NTP patients with high pause frequency (Table eight ). Similarly, DTP (60 minutes, two.64; P=0.001) and DNTP (HR, two.35; P=0.012) patients with loftier pause frequency showed increased bloodshed rate compared with the high‐pause‐frequency patients in the NOP groups (Table 8 ).
| Median Frequency (times/day) | NTP (N=248) | DTP (N=103) | DNTP (North=81) | ||||||
|---|---|---|---|---|---|---|---|---|---|
| 3 | 3 | 23 | |||||||
| N | Death | Bloodshed (%) | Northward | Death | Mortality (%) | N | Death | Mortality (%) | |
| High frequency | 132 | 10 | 7.6 | 52 | 12 | 23.1 | 42 | 9 | 21.four |
| Depression frequency | 116 | 13 | xi.two | 51 | seven | xiii.7 | 39 | six | xv.4 |
| P value within group a | 0.325 | 0.221 | 0.484 | ||||||
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Figure iii Intermediate intermission frequency on mortality rates inside the
| Frequency | DTP vs NTP a | DNTP vs NTP a | DNTP vs DTP a | NTP vs NOP a | DTP vs NOP a | DNTP vs NOP a | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 60 minutes (95% CI) | P value | Hour (95% CI) | P value | HR (95% CI) | P value | HR (95% CI) | P value | HR (95% CI) | P value | HR (95% CI) | P value | |
| High frequency | iii.42 (1.42–8.28) | 0.006 b | one.72 (1.08–2.75) | 0.023 b | 0.97 (0.35–two.72) | 0.959 | i.28 (0.68–2.40) | 0.449 | 2.64 (1.47–4.73) | 0.001 b | 2.35 (i.21–iv.59) | 0.012 b |
| Low frequency | 1.42 (0.55–3.71) | 0.469 | 1.30 (0.77–2.18) | 0.323 | 0.97 (0.30–3.14) | 0.959 | 0.78 (0.45–ane.37) | 0.386 | one.78 (0.84–3.78) | 0.134 | 1.70 (0.75–3.81) | 0.202 |
Figure4 shows the percentage of patients in different pause groups according to the causes of expiry. The leading causes of death in intermediate suspension patients are infection and malignancy. DTP and DNTP patients had a higher rate of infection‐related bloodshed than that of the NOP patients (DTP versus NOP, P=0.002; DNTP versus NOP, P=0.002; Table 9 ). Similarly, DTP and DNTP patients also had a higher rate of malignancy‐related decease compared with that of NOP patients (DTP versus NOP, P<0.001; DNTP versus NOP, P=0.004; Table 9 ). Cardiovascular (myocardial infarction, HF, and sudden cardiac death; P=0.084) and other (gastrointestinal haemorrhage, stroke, chronic obstructive pulmonary diseases, and uremia; P=0.785) causes of mortality rate were similar amidst these four groups of patients.
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Figure four Bloodshed charge per unit and causes of deaths in the iv groups of patients. Causes of cardiovascular deaths included myocardial infarction, heart failure, and sudden cardiac expiry. Other causes of decease included gastrointestinal bleeding, stroke, chronic obstructive pulmonary diseases, and uremia.
| Causes of Death | NTP vs NOP | DTP vs NOP | DNTP vs NOP | DTP vs NTP | DNTP vs NTP | DNTP vs DTP |
|---|---|---|---|---|---|---|
| Percent (%), P Value | Percentage (%), P Value | Percentage (%), P Value | Percentage (%), P Value | Per centum (%), P Value | Pct (%), P Value | |
| Infection | 2.4 vs 2.2 0.803 | half-dozen.viii vs ii.2 0.002 | seven.four vs 2.2 0.002 | half-dozen.8 vs two.4 0.048 | vii.four vs 2.4 0.038 | 7.iv vs 6.8 0.872 |
| Malignancy | 4.0 vs one.8 0.012 | half-dozen.8 vs 1.8 <0.001 | 6.2 vs one.viii 0.004 | 6.8 vs 4.0 0.272 | 6.2 vs 4.0 0.423 | half dozen.2 vs 6.viii 0.865 |
| Cardiovascular death | two.4 vs 1.4 0.167 | 3.9 vs 1.iv 0.032 | 2.v vs 1.4 0.395 | 3.9 vs 2. 0.453 | 2.five vs 2.four 0.980 | 2.5 vs 3.9 0.592 |
| Others a | 0.four vs 0.half dozen 0.751 | 1.0 vs 0.6 0.578 | one.ii vs 0.6 0.420 | one.0 vs 0.4 0.520 | i.2 vs 0.4 0.403 | ane.2 vs 1.0 0.864 |
| Mortality | 9.3 vs 5.9 0.029 | xviii.iv vs five.9 <0.001 | 18.5 vs 5.9 <0.001 | 18.4 vs 9.3 0.016 | 18.5 vs 9.3 0.024 | xviii.5 vs 18.four 0.990 |
Pct and causes of PPM implantation in different intermission groups are shown in Figure5. Compared with NOP patients, DNTP, DTP, and NTP patients had a college rate of sick sinus syndrome (DNTP versus NOP, P<0.001; DTP versus NOP, P=0.018; NTP versus NOP, P<0.001) and AVB (DNTP versus NOP, P<0.001; DTP versus NOP, P<0.001; NTP versus NOP, P<0.001) related PPM implantation (Table 10 ).
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Effigy 5 Causes for permanent pacemaker (
| Causes of PPM Implantation | NTP vs NOP | DTP vs NOP | DNTP vs NOP | DTP vs NTP | DNTP vs NTP | DNTP vs DTP |
|---|---|---|---|---|---|---|
| Pct (%), P Value | Per centum (%), P Value | Pct (%), P Value | Percent (%), P Value | Percentage (%), P Value | Per centum (%), P Value | |
| Total PPM | 7.vii vs 1.four <0.001 | 6.8 vs ane.4 <0.001 | 18.v vs 1.4 <0.001 | 6.8 vs 7.7 0.778 | eighteen.v vs 7.7 0.005 | 18.5 vs 6.eight 0.015 |
| SSS | 5.2 vs 0.8 <0.001 | ii.nine vs 0.eight 0.018 | 11.1 vs 0.eight <0.001 | ii.9 vs 5.2 0.341 | xi.1 vs five.2 0.066 | 11.one vs two.nine 0.025 |
| AVB | ii.0 vs 0.4 <0.001 | 2.9 vs 0.4 <0.001 | 4.9 vs 0.iv <0.001 | 2.ix vs 2.0 0.608 | 4.ix vs two.0 0.162 | 4.9 vs 2.9 0.476 |
| AF | 0.4 vs 0.ane 0.245 | ane.0 vs 0.one 0.023 | two.v vs 0.i <0.001 | 1.0 vs 0.four 0.520 | 2.5 vs 0.iv 0.089 | 2.5 vs one.0 0.426 |
| VT a | 0.0 vs 0.1 0.613 | 0.0 vs 0.1 0.745 | 0.0 vs 0.1 0.773 | 0.0 vs 0.0 … | 0.0 vs 0.0 … | 0.0 vs 0.0 … |
Discussion
Main Finding
This study has the post-obit major findings: (1) Intermediate interruption occurring at daytime or nighttime increased the risk of adverse cardiovascular events, including all‐cause hospitalization, cardiovascular cause of hospitalization, pacemaker implantation, new‐onset AF, new‐onset HF, and TIA, compared with those without pause; (ii) intermediate pause occurring at daytime, either daytime but or solar day plus nighttime, was associated with increased bloodshed rate than those whose pauses solely occurred at nighttime; and (iii) in patients with intermediate pauses at daytime, those with sick sinus pattern and high occurrence frequency were at high chance for bloodshed.
Intermediate Versus Long Pauses on Mortality
Sinus pauses greater than 3 seconds in duration may cause syncope or presyncope, despite some patients only have giddiness or whirling.1 Current American and European guidelines recommended that permanent cardiac pacing is indicated in patients with pauses ≥3.0 seconds for ventricular activity, either in sinoatrial node dysfunction or abnormality in atrioventricular conduction. However, the current 3‐second criterion is an arbitrary clinical ascertainment with a low specificity.3 Hilgard et al found 47 asymptomatic patients with long (≥3 seconds) pause from 6470 sequent 24‐60 minutes Holter recordings. They reported that no survival benefit was constitute in these patients receiving pacemaker therapy or non.9 With this three‐second criteria, Saba et al compared the unpaced long (≥3 seconds) pause patients (n=70) with the no pause (<iii seconds) patients (n=81) and found no departure in survival charge per unit after 2.2 years of follow‐up.10 Similarly, in patients with intermediate (≥2 seconds) pauses, Mazuz et al found no differences in clinical outcomes betwixt paced and unpaced patients.11 The lack of survival benefit in pacing the long/intermediate pause patients may arise from (1) brusk observation elapsing in these studies and (ii) AF patients whose criteria for pacing is >5‐2d pause were not excluded.
In this study excluding patients with AF and followed upward to viii years, we found that intermediate pauses occurring at either daytime or dark increased the risk of agin cardiovascular events, including all/cardiovascular cause of hospitalization, new‐onset AF/HF, pacemaker implantation, and TIA. Intermediate interruption at daytime was associated with increased bloodshed charge per unit than that at nighttime. We too establish that high pause occurrence frequency was associated with increased mortality rate, suggesting that these intermediate pauses affected patient outcome. To the best of our knowledge, this is the kickoff written report to clarify the long‐term (>viii years) relationship between intermediate pauses and morbidities. Therefore, intermediate break occurring at daytime might not be a benign class if patients are followed in a long‐term duration. Futurity studies are warranted to elucidate the clinical significance of this association.
Intermediate Suspension at Night Versus Daytime on Cardiovascular Risk
Sinus pauses occurring in the daytime may cause syncope and were considered to be clinically meaning. On the other manus, nighttime bradycardia and pause episodes are often idea to be beneficial because they did not produce symptoms. In 50 medical students without cardiovascular diseases receiving 24‐60 minutes Holter monitoring, Brodsky found that 28% had sinus interruption of >1.75 seconds during slumber, simply no adverse events or bloodshed were reported.12 Similarly, an observational study likewise showed that upward to 4% to 10% of salubrious subjects had sinus pause of ≥two seconds during slumber without adverse clinical events.thirteen These findings suggested that nighttime suspension was a beneficial physiological response because of the suppression of autonomic control during sleep. Even so, in this written report, we establish that intermediate break at nighttime was associated with an increased risk of agin cardiovascular events, including hospitalization, pacemaker implantation, new‐onset AF/HF, and TIA, compared with those without pauses. I possibility for this discrepancy is that most of our enrolled patients are not healthy subjects, having chronic diseases of diabetes mellitus, hypertension, HF, and coronary heart illness. Our data correspond a real‐globe practice results, and nearly of the patients in clinics did have multiple comorbidities. Further studies are needed to clarify the clinical significance of night intermediate intermission.
Intermediate Pauses and New‐Onset AF
Sick sinus syndrome is the aging process involving the sinoatrial node and atrial myocardium, leading atrial fibrosis and the evolution of AF.xiv Bradycardia per se might stimulate atrial ectopic beats and heighten greater dispersion of atrial refractoriness, and both are vital factors for initiating AF.16 An experimental study besides found that interrupted electric connectedness betwixt the sinoatrial node and pulmonary veins might facilitate flare-up firing of the pulmonary veins and occurrence of AF.17 Therefore, up to 50% of sick sinus syndrome patients with long pauses are accompanied past paroxysmal supraventricular tachycardia, and most of them were AF.18 In this study, nosotros observed that patients with only intermediate pauses, either at daytime or dark, are associated increased risk of new‐onset AF, which is consequent with previous clinical and experimental studies. This finding suggests that patients with intermediate pauses might share similar pathophysiological processes with sick sinus syndrome patients. Early intervention, including medication and catheter ablation to prevent atrial remodeling, might decrease the risk of developing AF, even in patients with intermediate pauses. Farther prospective studies are warranted to validate this hypothesis.
Intermediate break occurring at daytime or dark increased the adventure of adverse cardiovascular events, and these pauses occurring at daytime, either daytime only or daytime plus dark, were correlated to raising mortality charge per unit in this study. Although PPM implantation is not indicated for patients with intermediate pause according to the current guidelines, these patients did have increased run a risk for future pacemaker implantation observed in this written report.i Intermediate pause might therefore exist a subclinical harbinger for future long pauses that warrant pacemaker implantation, especially in those who adult mild symptoms such as dizziness or whirling. In daily clinical practice, physicians should pay more than attending to this group of patients and intensively follow them up. An electrophysiology study might be considered to elucidate the uncovered sinus or atrioventricular nodal dysfunction in intermediate pause patients with presyncope or fainting.20 Clinicians should also be aware of the symptoms of AF and HF, such every bit palpitations or exercise intolerance in patients with intermediate pauses because they have increased risk of new‐onset AF and HF. Keeping an eye on these symptoms and timely administration/adjustment of anticoagulation and HF medication might prevent stroke and HF hospitalization in these patients. Finally, early and acceptable handling for underlying comorbidities might also be helpful to reduce future cardiovascular chance in intermediate pause patients.
Written report Limitations
Several limitations be in this study. First, our written report was designed retrospectively with variable follow‐up periods amidst patients. Farther prospective studies are still necessary to validate our findings. Second, because of the lack of symptoms, patients with intermediate pauses did not routinely receive electrophysiological written report. We therefore could not elucidate the causes of intermediate pauses, such as sinus node dysfunction or atrioventricular nodal dysfunction in these patients. Third, medications used might touch the heart rate and pauses. We did not know whether these patients were compliant with the prescribed medication. This factor might besides confound our results. Fourth, a 24‐hr Holter monitor is a relatively curt monitoring period compared with new implantable/wearable loop recorders that can have up to 3 years of continuous rhythm monitoring. Further studies using loop recorders are still needed to verify our findings. Finally, elevated vagal tone during sleep might too contribute to the adverse cardiovascular events in patients with NTP. In this study, we did not record the exact sleep/awake time in the 24‐hour monitoring period. We therefore defined the daytime (viii:00 am–viii:00 pm) and nighttime (8:00 pm–8:00 am) regardless patients' slumber/awake status. Previous studies showed that high vagal activeness during sleep was associated with elevated heart rate variability, in item the high‐frequency power of the spectral analysis.21 Further studies are needed to elucidate how vagal tone reflected past centre rate variability parameters contributes to the cardiovascular risk in patients with NTP.
Conclusion
In patients with intermediate pauses, adverse cardiovascular risk is increased compared with those without intermediate pauses. Patients with intermediate pauses occurring at daytime are associated with a higher bloodshed charge per unit than that occurring exclusively at dark during long‐term follow‐upwardly.
Sources of Funding
This report was supported by NSC grants 100‐2314‐B‐075‐046‐MY3, 101‐2314‐B‐010‐057‐MY3, and 101‐2314‐B‐075‐056‐MY3 and Taipei Veterans General Hospital grants V102C‐054, V102E7‐002, V103E7‐001, V103C‐095, and VGHUST102‐G1‐1‐i.
Disclosures
None.
Footnotes
References
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Source: https://www.ahajournals.org/doi/10.1161/jaha.118.009034
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