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Peer-reviewedCC BY 4.0Frontiers in Cardiovascular Medicine

Device-detected new-onset atrial fibrillation after dual-chamber pacemaker implantation in patients with sick sinus syndrome under managed ventricular pacing: a risk nomogram from the 3-month landmark

  • Jin-Mei Xie1
  • Cheng-Hua Shan1
  • Ying-Jun Xiao2
  • Jie Ma3
  • Ren-Rong Lu3
  • Zong-Jie Zheng2
  1. 1Department of Electrocardiogram Diagnosis, Sanming First Hospital Affiliated to Fujian Medical University
  2. 2Department of Ultrasound Medicine, Sanming First Hospital Affiliated to Fujian Medical University
  3. 3Department of Cardiovascular Medicine, Sanming First Hospital Affiliated to Fujian Medical University
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Abstract

Background: New-onset atrial fibrillation ( N OAF) is common after dual-chamber pacemaker implantation, but existing prediction models were derived from mixed populations of patients with sick sinus syndrome (SSS) and atrioventricular block and included heterogeneous pacing strategies.

Methods: In this single-centre retrospective cohort study, consecutive patients with SSS who received a first permanent Medtronic dual-chamber pacemaker with managed ventricular pacing (MVP) enabled as the default strategy were screened. Patients with atrial fibrillation or an atrial high-rate episode (AHRE) within 3 months after implantation were excluded, and prediction time started at this 3-month landmark, with atrial pacing percentage (AP%) and ventricular pacing percentage (VP%) measured at that visit. Patients implanted in 2015–2021 formed the development cohort ( n = 322), and those implanted in 2022–2025 formed a temporal validation cohort ( n = 121) reserved exclusively for validation. Twenty-six candidate predictors were assessed by univariable and multivariable Cox regression with backward Akaike information criterion (AIC) selection. Internal validation repeated the complete model-building procedure within 2,000 bootstrap samples. Temporal performance was assessed using discrimination and calibration at 1, 2 and 3 years after the landmark.

Results: NOAF occurred in 90 of 322 development patients (28.0%) during a median follow-up of 41.6 months [interquartile range (IQR), 13.7–80.1], and in 28 of 121 temporal validation patients (23.1%) during a median follow-up of 30.5 months (IQR, 8.8–45.9). Age (hazard ratio [HR] per year, 1.043; 95% confidence interval [CI], 1.019–1.067), maximum P-wave duration (Pmax; HR per 10 ms, 1.200; 95% CI, 1.085–1.326), left atrial volume index (LAVi; HR per 1 mL/m2, 1.051; 95% CI, 1.030–1.073), AP% > 50% (HR, 1.845; 95% CI, 1.198–2.840) and VP% > 40% (HR, 1.898; 95% CI, 1.045–3.446) were independently associated with NOAF. The apparent C-index was 0.735; repeating the complete model-building procedure within 2,000 bootstrap samples gave a mean optimism of 0.036 and an optimism-corrected C-index of 0.6992. In temporal validation the C-index was 0.769 (95% CI, 0.639–0.873) and cumulative/dynamic AUC values were 0.753, 0.881 and 0.916 at 1, 2 and 3 years after the landmark. Calibration-in-the-large was −0.17, 0.24 and 0.35 and calibration slopes were 0.90, 0.99 and 0.98 at 1, 2 and 3 years, respectively. The 1-year calibration estimate remained least precise, with only five NOAF events by 1 year in the validation cohort.

Conclusion: In patients with SSS who remained free of atrial arrhythmia through the 3-month post-implantation landmark, a five-variable landmark model showed moderate optimism-corrected discrimination in the development cohort and promising same-centre temporal validation performance, particularly at 2 and 3 years after the landmark. The limited number of validation events, particularly at 1 year, warrants cautious interpretation. Prospective multicentre external validation is required before clinical implementation.

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Cite

BibTeXRIS
BibTeX
@article{xie2026devicedetected,
  title = {{Device-detected new-onset atrial fibrillation after dual-chamber pacemaker implantation in patients with sick sinus syndrome under managed ventricular pacing: a risk nomogram from the 3-month landmark}},
  author = {Jin-Mei Xie and Cheng-Hua Shan and Ying-Jun Xiao and Jie Ma and Ren-Rong Lu and Zong-Jie Zheng},
  journal = {Frontiers in Cardiovascular Medicine},
  year = {2026},
  month = nov,
  doi = {10.3389/fcvm.2026.1989202},
  url = {https://www.frontiersin.org/articles/10.3389/fcvm.2026.1989202/full},
  note = {CC BY 4.0},
}
RIS
TY  - JOUR
TI  - Device-detected new-onset atrial fibrillation after dual-chamber pacemaker implantation in patients with sick sinus syndrome under managed ventricular pacing: a risk nomogram from the 3-month landmark
AU  - Jin-Mei Xie
AU  - Cheng-Hua Shan
AU  - Ying-Jun Xiao
AU  - Jie Ma
AU  - Ren-Rong Lu
AU  - Zong-Jie Zheng
PY  - 2026
DA  - 2026/11/05
JO  - Frontiers in Cardiovascular Medicine
DO  - 10.3389/fcvm.2026.1989202
UR  - https://www.frontiersin.org/articles/10.3389/fcvm.2026.1989202/full
AB  - Background: New-onset atrial fibrillation ( N OAF) is common after dual-chamber pacemaker implantation, but existing prediction models were derived from mixed populations of patients with sick sinus syndrome (SSS) and atrioventricular block and included heterogeneous pacing strategies.  Methods: In this single-centre retrospective cohort study, consecutive patients with SSS who received a first permanent Medtronic dual-chamber pacemaker with managed ventricular pacing (MVP) enabled as the default strategy were screened. Patients with atrial fibrillation or an atrial high-rate episode (AHRE) within 3 months after implantation were excluded, and prediction time started at this 3-month landmark, with atrial pacing percentage (AP%) and ventricular pacing percentage (VP%) measured at that visit. Patients implanted in 2015–2021 formed the development cohort ( n = 322), and those implanted in 2022–2025 formed a temporal validation cohort ( n = 121) reserved exclusively for validation. Twenty-six candidate predictors were assessed by univariable and multivariable Cox regression with backward Akaike information criterion (AIC) selection. Internal validation repeated the complete model-building procedure within 2,000 bootstrap samples. Temporal performance was assessed using discrimination and calibration at 1, 2 and 3 years after the landmark.  Results: NOAF occurred in 90 of 322 development patients (28.0%) during a median follow-up of 41.6 months [interquartile range (IQR), 13.7–80.1], and in 28 of 121 temporal validation patients (23.1%) during a median follow-up of 30.5 months (IQR, 8.8–45.9). Age (hazard ratio [HR] per year, 1.043; 95% confidence interval [CI], 1.019–1.067), maximum P-wave duration (Pmax; HR per 10 ms, 1.200; 95% CI, 1.085–1.326), left atrial volume index (LAVi; HR per 1 mL/m2, 1.051; 95% CI, 1.030–1.073), AP% > 50% (HR, 1.845; 95% CI, 1.198–2.840) and VP% > 40% (HR, 1.898; 95% CI, 1.045–3.446) were independently associated with NOAF. The apparent C-index was 0.735; repeating the complete model-building procedure within 2,000 bootstrap samples gave a mean optimism of 0.036 and an optimism-corrected C-index of 0.6992. In temporal validation the C-index was 0.769 (95% CI, 0.639–0.873) and cumulative/dynamic AUC values were 0.753, 0.881 and 0.916 at 1, 2 and 3 years after the landmark. Calibration-in-the-large was −0.17, 0.24 and 0.35 and calibration slopes were 0.90, 0.99 and 0.98 at 1, 2 and 3 years, respectively. The 1-year calibration estimate remained least precise, with only five NOAF events by 1 year in the validation cohort.  Conclusion: In patients with SSS who remained free of atrial arrhythmia through the 3-month post-implantation landmark, a five-variable landmark model showed moderate optimism-corrected discrimination in the development cohort and promising same-centre temporal validation performance, particularly at 2 and 3 years after the landmark. The limited number of validation events, particularly at 1 year, warrants cautious interpretation. Prospective multicentre external validation is required before clinical implementation.
SN  - 2297-055X
ER  -