Prophylactic pacemaker use to allow β-blocker therapy in patients with chronic heart failure with bradycardia

Background Although the benefits of β-blocker therapy for patients with congestive heart failure (CHF) are independent of pretreatment heart rate, patients with chronic systolic heart failure and low resting heart rates are often excluded from β-blocker therapy. We investigated the effectiveness and cost-effectiveness of prophylactic pacemaker insertion to facilitate β-blocker use in these patients. Methods A Markov model simulated the natural history of a cohort of clinically stable patients with CHF (ejection fraction ≤35%, mean age 60 years) with resting heart rates of <68 beat/min. Two strategies were evaluated: (1) conventional therapy (conventional)—the risks for death and hospitalization were derived from the angiotensin-converting enzyme inhibitor arm of the SOLVD treatment trial; and (2) pacemaker insertion with atrial pacing and carvedilol therapy (pacemaker-carvedilol)—risk reductions for death and CHF-related hospitalizations for carvedilol compared with conventional therapy were derived from the US Carvedilol Heart Failure Study. We assumed full carvedilol benefits for 2 years, declining benefits for the next 3 and no additional benefits after 5 years, whereas pacemaker-related adverse events persisted. Results In the base case, the pacemaker-carvedilol strategy increased mean survival by 1.3 years at an incremental cost of $7800, for an incremental cost-effectiveness of $6100 per year of life saved. Results were most sensitive to theoretical pacing-induced harm, changes in hospitalization cost, and reductions in β-blocker benefits. Conclusion Prophylactic pacemaker insertion to facilitate β-blocker treatment in patients with CHF with low resting heart rates has the potential to produce clinical benefits in a highly cost-effective manner.