Epidemiology of pacemaker implantation in the community: findings from the Framingham Heart Study

BACKGROUND: The epidemiology of permanent pacemaker [PPM] implantation in the community setting is unclear. METHODS: We examined Framingham Heart Study cohort participants aged ≥45 years, without a history of PPM, who attended ≥1 exam cycle during 1972-2019. Fine-Gray subdistribution hazard models were used to calculate subdistribution hazard ratios [sHR] and 95% confidence intervals [CI] for the association between clinical characteristics (age, sex, body mass index [BMI], systolic and diastolic blood pressure [BP], smoking, hypertension treatment, diabetes, history of atrial fibrillation [AF], myocardial infarction, and heart failure) and incident PPM implantation. For continuous measures, sHRs were expressed per 1 standard deviation [SD]. Multiple imputation was used to account for missing data. RESULTS: A total of 11,993 participants contributed 44,711 exam cycles (mean age 63 ± 11 years, 56% women) to the analysis. During follow-up (mean 4.9 ± 2.2 years), there were 382 PPM implantations and 4298 deaths. In multivariable-adjusted models, the following factors were associated with incident PPM implantation: age (sHR [per 1 SD = 11 years] =1.39), female sex (sHR = 0.49), BMI (sHR [per 1 SD = 5.1 kg/m²] =1.17), higher systolic BP (sHR [per 1 SD = 20 mmHg] =1.46), lower diastolic BP (sHR [per 1 SD = 10 mmHg] = 0.68), hypertension treatment (sHR = 1.40), smoking (sHR = 0.59), and history of AF (sHR = 2.60). CONCLUSIONS: Higher age, BMI, systolic BP, hypertension treatment, and history of AF were associated with increased rate of PPM implantation, while female sex, smoking, and diastolic BP showed an inverse association. Further study is needed to confirm these findings.