Prevalence and predictors of pacing-induced cardiomyopathy (picm) in a southeast asian population

Background

Right ventricular (RV) pacing is effective for bradyarrhythmia management but may lead to pacing-induced cardiomyopathy (PICM) due to electrical and mechanical dyssynchrony. PICM is an underrecognized cause of heart failure among pacemaker recipients with prevalance varying widely across studies. Despite increasing pacemaker utilization, data on PICM prevalence and predictors in Southeast Asian populations remain limited. Identifying the predictors is essential to guide early physiological pacing strategies and prevent reverse remodeling.

Objective

To determine the prevalence and independent predictors of PICM among patients undergoing permanent pacemaker implantation at our National Heart Institute, Malaysia.

Methods

This retrospective cohort study included all patients who underwent permanent pacemaker implantation between 2013 and 2023 at the National Heart Institute (IJN), Malaysia, with available pre- and post-implant echocardiographic assessments. PICM was defined as a reduction in left ventricular ejection fraction (LVEF) of >10% from a baseline >50% to <50%, after excluding alternative causes of cardiomyopathy such as ischemic, valvular, or infitrative disease. Demographic, clinical, electrocardiographic, and device-related variables including pacing indication, QRS duration, and RV pacing burden were collected and analyzed. Univariable and multivariable logistic regression analyses were performed to identify independent predictors of PICM.

Results

Among 4,137 pacemaker recipients, 1053 (25.5%) fulfilled inclusion criteria, and 244 (23.2%) developed PICM. Compared with non-PICM patients, those with PICM were more likely to be male (61.1% vs. 44.6%, p < 0.001), implanted for atrioventricular block (52.5% vs. 37.5%, p < 0.001), and to have post-implant QRS ≥140 ms (61.9% vs. 42.5%, p < 0.001) and RV pacing burden >40% (81.1% vs. 47.0%, p < 0.001).

In multivariate analysis, male sex (OR 1.62, 95% CI 1.18–2.23; p = 0.003) and higher RV pacing burden (OR 1.02 per %, 95% CI 1.01–1.02; p < 0.001) remained independent predictors. The median time to PICM onset was 3 years (IQR 1–5 years).

Conclusion

This is the first study from a high-volume Southeast Asian centre to report the prevalence and predictors of PICM in a multiethnic population. PICM affected nearly one-quarter of pacemaker recipients in this large Southeast Asian cohort. Independent predictors included male gender and higher RV pacing burden, with additional associations with AV block indication and wider post-implant QRS duration. These findings underscore the importance of routine echocardiographic surveillance and consideration of early physiological pacing strategies to mitigate PICM risk. Future prospective studies are warranted to validate these predictors and to develop a dedicated PICM risk calculator that may guide individualized pacing strategy selection.CONSORT DIAGRAM and PREVALANCEPICM PREDICTORS ANALYSIS