Atrioventricular (AV) synchronous pacing reduces left ventricular (LV) outflow tract obstruction and symptoms in patients with obstructive hypertrophic cardiomyopathy (HC). The duration of gradient reduction, if pacing is discontinued for a prolonged period of time, is unknown. This question is addressed in the present randomized double-blind crossover study comparing continued with inactivated pacing. Ten patients, successfully paced for > or = 6 months, were randomized to continue pacing or to have their pacemakers inactivated after baseline examinations, including echo-Doppler imaging, exercise testing, and a quality-of-life questionnaire. When entering the study, the patients were in New York Heart Association functional classes I to II. After pacemaker programming, examinations were repeated at 1, 4, and 12 weeks. At the 12-week follow-up the alternate pacing mode was programmed, and the patient entered the second study arm. Premature pacemaker pacing occurred if severe clinical deterioration or a significant increase of the LV outflow tract obstruction were evident. Three patients started in the inactive mode and 7 patients in the active mode. All patients who started with the pacemaker inactivated required early reprogramming due to return of symptoms after 7, 10, and 13 days, respectively. All 7 patients who started in the active pacing mode completed the first period; however, after reprogramming to the inactive mode they required early activation after 1 to 20 days due to reappearance of intolerable subjective symptoms. The LV outflow tract gradient increased significantly after inactivation of pacing in all patients (22 +/- 21 mm Hg to 47 +/- 21 mm Hg). Thus, AV synchronous pacing effectively relieves symptoms and reduces the LV outflow tract gradient in patients with obstructive HC. This improvement, which is rapidly established with the initiation of cardiac pacing, is not persistent after cessation of pacing. Reinitialization of pacing promptly reduces the LV outflow tract obstruction and relieves symptoms to a preexisting extent.