From the Guidelines
Atrial fibrillation with bradycardia should be managed with a permanent pacemaker as the recommended treatment, particularly if the slow heart rate is due to medications needed for rate control or if the patient has intrinsic conduction disease, as supported by the most recent guidelines 1. When managing atrial fibrillation with bradycardia, it is essential to consider the patient's symptoms and underlying causes. The treatment approach should prioritize minimizing morbidity, mortality, and improving quality of life.
Key Considerations
- Before pacemaker implantation, any reversible causes should be addressed, including stopping or reducing medications that slow heart rate such as beta-blockers, calcium channel blockers, or digoxin 1.
- If bradycardia is medication-induced but the patient requires these medications for rate control, a "pace and ablate" strategy may be considered, involving pacemaker implantation followed by AV node ablation, as suggested by recent guidelines 1.
- For temporary management of symptomatic bradycardia, atropine 0.5mg IV can be administered, repeated every 3-5 minutes up to a maximum of 3mg.
- In emergency situations, transcutaneous pacing may be necessary until a permanent solution is implemented.
Underlying Mechanism
The underlying mechanism typically involves either medication effects or sick sinus syndrome (tachy-brady syndrome), where the sinus node dysfunction causes periods of bradycardia alternating with atrial fibrillation.
Monitoring and Follow-up
Regular monitoring of heart rate and symptoms is essential, with follow-up ECGs to assess rhythm control and pacemaker function if implanted.
Guideline Recommendations
The 2022 AHA/ACC/HFSA guideline for the management of heart failure supports the use of anticoagulation among those with atrial fibrillation and heart failure, but not in patients with heart failure without atrial fibrillation 1.
Treatment Approach
The treatment approach should prioritize minimizing morbidity, mortality, and improving quality of life, and a permanent pacemaker is the recommended treatment for symptomatic bradycardia in atrial fibrillation, as supported by the most recent guidelines 1.
From the Research
Atrial Fibrillation with Bradycardia
- Atrial fibrillation (AF) can present with slow ventricular-response, and bradycardia can facilitate the emergence of AF 2.
- Bradycardia could be the inciting mechanism for the occurrence of AF, and when the bradycardia is eliminated, AF may not recur 2.
- The development of bradycardia-induced ventricular arrhythmias (VAs) can be a life-threatening situation, and pacing at rates ~80-110 bpm can avert this sequence 2.
Management of Atrial Fibrillation with Bradycardia
- Rate control is a better initial treatment for patients with atrial fibrillation and heart failure, and pharmacological rate control should be considered initially in patients with AF associated with congestive heart failure (CHF) 3.
- Amiodarone is the only recommended antiarrhythmic drug in the recent therapeutic guidelines for CHF, and can be used for both rhythm and rate control of AF 3.
- Catheter ablation (CA) can be applicable even in AF associated with CHF, but the results of CA are closely associated with the clinical and electrophysiological characteristics in each patient 3.
Evaluation and Management of Bradycardia
- Bradycardia is a commonly observed arrhythmia, and treatment should rarely be prescribed solely on the basis of a heart rate lower than an arbitrary cutoff or a pause above certain duration 4.
- Assessment of symptoms is a critical component in the evaluation and management of bradycardia, and the 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients with Bradycardia and Cardiac Conduction Delay emphasizes the importance of evaluating and managing disease states 4.
Comparative Effectiveness of Antiarrhythmic Drugs
- Amiodarone, class 1C agents, and sotalol are more effective for rhythm control of AF compared to dronedarone, while dofetilide had similar efficacy 5.
- The risk of stroke was similar among all groups, and all-cause mortality was lowest in patients treated with class 1C agents 5.
Impact of Bradycardia and Atrial Fibrillation on Outcomes
- Emergent bradycardia and AF did not appear to impact outcomes in patients with stable coronary artery disease treated with ivabradine 6.
- There was no difference in outcomes over the course of the study in ivabradine-treated patients with and without emergent bradycardia, and neither was there an increase in the rate of primary endpoint after emergent bradycardia was recorded 6.