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

BACKGROUND Although the benefits of beta-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 beta-blocker therapy. We investigated the effectiveness and cost-effectiveness of prophylactic pacemaker insertion to facilitate beta-blocker use in these patients. METHODS A Markov model simulated the natural history of a cohort of clinically stable patients with CHF (ejection fraction < or = 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 beta-blocker benefits. CONCLUSION Prophylactic pacemaker insertion to facilitate beta-blocker treatment in patients with CHF with low resting heart rates has the potential to produce clinical benefits in a highly cost-effective manner.