It has been shown that either dual-chamber or atrial pacing may be better than ventricular single-chamber pacing, but the long-term effect of dual-chamber pacing on cardiac sympathetic activity is unclear. The aim of this study was to assess the effect of long-term dual-chamber pacing on cardiac sympathetic activity, compared with atrial pacing and unpaced individuals. We studied 11 patients with dual-chamber pacemakers (Group D), nine with atrial single-chamber pacemakers (Group A) over the long term (mean 44 +/- 36 months) and 10 normal individuals without cardiac pacing. All underwent myocardial 123I-metaiodobenzylguanidine (MIBG) imaging to assess cardiac sympathetic activity. The heart-to-mediastinum (H/M) MIBG uptake ratio and the MIBG washout rate from the myocardium were calculated. Echocardiography was performed in all patients with cardiac pacing to assess left ventricular function. In Group D, the H/M ratio on delayed images was significantly lower than that of Group A (1.82 +/- 0.51 vs 2.56 +/- 0.50, P < 0.001) and normal individuals (2.65 +/- 0.35, P < 0.05). The myocardial MIBG washout rate of Group D was significantly higher than that of either Group A (52 +/- 13% vs 36 +/- 8%, P < 0.01) or normal individuals (31 +/- 7%, P < 0.05). Neither the H/M ratio nor MIBG washout rate differed significantly between patients in Group A and normal individuals. Furthermore, the echocardiographic parameters did not differ significantly between the two pacing groups. We conclude that long-term ventricular pacing, even in the presence of atrioventricular synchrony, accelerates cardiac sympathetic activity without deteriorating left ventricular function.