Dual-chamber pacing or ventricular backup pacing in patients with an implantable defibrillator: the Dual Chamber and VVI Implantable Defibrillator (DAVID) Trial

JAMA. 2002 Dec 25;288(24):3115-23. doi: 10.1001/jama.288.24.3115.


Context: Implantable cardioverter defibrillator (ICD) therapy with backup ventricular pacing increases survival in patients with life-threatening ventricular arrhythmias. Most currently implanted ICD devices provide dual-chamber pacing therapy. The most common comorbid cause for mortality in this population is congestive heart failure.

Objective: To determine the efficacy of dual-chamber pacing compared with backup ventricular pacing in patients with standard indications for ICD implantation but without indications for antibradycardia pacing.

Design: The Dual Chamber and VVI Implantable Defibrillator (DAVID) Trial, a single-blind, parallel-group, randomized clinical trial.

Setting and participants: A total of 506 patients with indications for ICD therapy were enrolled between October 2000 and September 2002 at 37 US centers. All patients had a left ventricular ejection fraction (LVEF) of 40% or less, no indication for antibradycardia pacemaker therapy, and no persistent atrial arrhythmias.

Interventions: All patients had an ICD with dual-chamber, rate-responsive pacing capability implanted. Patients were randomly assigned to have the ICDs programmed to ventricular backup pacing at 40/min (VVI-40; n = 256) or dual-chamber rate-responsive pacing at 70/min (DDDR-70; n = 250). Maximal tolerated medical therapy for left ventricular dysfunction, including angiotensin-converting enzyme inhibitors and beta-blockers, was prescribed to all patients.

Main outcome measure: Composite end point of time to death or first hospitalization for congestive heart failure.

Results: One-year survival free of the composite end point was 83.9% for patients treated with VVI-40 compared with 73.3% for patients treated with DDDR-70 (relative hazard, 1.61; 95% confidence interval [CI], 1.06-2.44). The components of the composite end point, mortality of 6.5% for VVI-40 vs 10.1% for DDDR-70 (relative hazard, 1.61; 95% CI, 0.84-3.09) and hospitalization for congestive heart failure of 13.3% for VVI-40 vs 22.6% for DDDR-70 (relative hazard, 1.54; 95% CI, 0.97-2.46), also trended in favor of VVI-40 programming.

Conclusion: For patients with standard indications for ICD therapy, no indication for cardiac pacing, and an LVEF of 40% or less, dual-chamber pacing offers no clinical advantage over ventricular backup pacing and may be detrimental by increasing the combined end point of death or hospitalization for heart failure.

Publication types

  • Clinical Trial
  • Comparative Study
  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adrenergic beta-Antagonists / therapeutic use
  • Aged
  • Amiodarone / therapeutic use
  • Angiotensin-Converting Enzyme Inhibitors / therapeutic use
  • Anti-Arrhythmia Agents / therapeutic use
  • Anticoagulants / therapeutic use
  • Arrhythmias, Cardiac / complications
  • Arrhythmias, Cardiac / therapy*
  • Cardiac Pacing, Artificial*
  • Cardiovascular Agents / therapeutic use
  • Catheter Ablation
  • Defibrillators, Implantable*
  • Digoxin / therapeutic use
  • Diuretics / therapeutic use
  • Female
  • Heart Failure / epidemiology*
  • Humans
  • Male
  • Middle Aged
  • Pacemaker, Artificial*
  • Single-Blind Method
  • Survival Analysis
  • Tachycardia, Ventricular / therapy
  • Ventricular Dysfunction, Left / complications
  • Ventricular Dysfunction, Left / therapy*
  • Warfarin / therapeutic use


  • Adrenergic beta-Antagonists
  • Angiotensin-Converting Enzyme Inhibitors
  • Anti-Arrhythmia Agents
  • Anticoagulants
  • Cardiovascular Agents
  • Diuretics
  • Warfarin
  • Digoxin
  • Amiodarone