Long-Term Mortality and Heart Failure Risk After Pacemaker Implantation: A Nationwide Cohort Study

BackgroundThe long-term risk of heart failure (HF) and mortality following permanent pacemaker (PPM) implantation remains controversial and underexplored. ObjectivesThis study evaluated these risks and assessed the survival benefits of upgrading to cardiac resynchronisation therapy (CRT) and the impact of standard HF medications. MethodsUsing the Korean National Health Insurance Service database, we identified 32,216 patients who underwent PPM implantation without preexisting HF between 2008 and 2019. ResultsDuring the median 3.8-year follow-up period, pacemaker-associated HF (PaHF) and all-cause death occurred in 4170 (12.9%) patients, and 6184 (19.2%) died. PaHF development was strongly associated with all-cause mortality, with a significantly higher risk in the PaHF group than in the non-PaHF group (hazard ratio [HR] 3.11, 95% confidence interval [CI] 2.93-3.32) after adjusting for immortal-time bias and confounders. PaHF incidence and associated mortality were highest within the first 6 months, however, persisted throughout follow-up, with a mortality risk resurgence approximately five years post-implantation. In a propensity score-matched cohort of PaHF patients (n=1,455), CRT-upgrade was associated with a significantly lower risk of mortality (HR 0.34, 95% CI 0.24- 0.47), as were angiotensin receptor-neprilysin inhibitor (ARNI) (HR 0.28, 95% CI 0.14-0.54) and beta-blockers (HR 0.75, 95% CI 0.61-0.93). ConclusionsPaHF development independently predicted mortality post-PPM implantation, while CRT-upgrade and the use of beta-blockers or ARNI were associated with improved survival. Therefore, for PaHF patients, an immediate switching into CRT or conduction system pacing combined with optimal HF medications, may be required to mitigate the ongoing mortality risk.