The British Pacing and Electrophysiology Group guidelines for pacemaker prescription recommend single chamber atrial pacing as the most appropriate pacing mode for sinus node disease in the absence of atrioventricular conduction disturbance.1 As such it offers a rare combination of maximum clinical effectiveness for the minimum cost and a good training opportunity. However, it seems that this message has yet to be translated into pacing practice in the UK.

In this issue of Heart, Clarke et alretrospectively analyses the pacing activity for sinus node disease in a tertiary pacing centre over five years.2 They conclude that in their centre £103 000 per year could have been saved by more judicious use of AAI pacing, largely by reducing the DDD implant rate. It seems likely that these potential savings are equally applicable to the rest of the UK. Current pacemaker prescribing for sinus node disease is frequently illogical, ignores current evidence, and misses out on training opportunities for junior staff.

The evidence to support atrial based pacing for sinus node disease, rather than single chamber ventricular pacing, is very strong. Numerous retrospective studies have demonstrated that mortality and morbidity are greater in ventricular only paced patients,3-5 and that the progression to chronic atrial fibrillation (AF) is less common in patients with atrial based pacing.3-10 Although these data may be criticised for the potential biases inherent in retrospective studies, since 1994 data have been available from the first prospective randomised study.11 Andersen et al were able to demonstrate a reduction in the frequency of AF and incidence of thromboembolism (5% v 18%) with atrial pacing after three years of follow up. The most recent analysis of this study (at 5.5 years of follow up) has also shown a significant reduction in all cause mortality (35.5% v …