Can you still be in atrial fibrillation (Afib) with a pacemaker?

From the Guidelines

Yes, you can still be in atrial fibrillation (Afib) with a pacemaker, as pacemakers are primarily designed to prevent the heart from beating too slowly and may not necessarily prevent or control Afib, which is a rapid, irregular heart rhythm originating in the atria.

Key Points to Consider

• Standard pacemakers monitor and regulate the heart's lower chambers (ventricles) but don't always control the upper chambers (atria) where Afib occurs.
• If you have a pacemaker and develop Afib, your doctor may prescribe medications such as beta-blockers (metoprolol, atenolol), calcium channel blockers (diltiazem, verapamil), or antiarrhythmic drugs (amiodarone, sotalol) to control your heart rate or rhythm, as suggested by the 2024 ESC guidelines for the management of atrial fibrillation 1.
• Some patients may require anticoagulants like warfarin, apixaban, or rivaroxaban to prevent blood clots.
• Certain advanced pacemakers called cardiac resynchronization therapy (CRT) devices or those with specific atrial algorithms may help manage Afib better, but they don't guarantee complete prevention.
• The decision to use AV nodal ablation in conjunction with permanent pacemaker implantation should be made on a case-by-case basis, considering the patient's symptoms, quality of life, and response to medical treatment, as discussed in the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation 1.

Management and Treatment

• Evaluation and dynamic reassessment are crucial in managing patients with permanent Afib, as outlined in the AF-CARE approach 1.
• Rate control target should aim for a resting heart rate <110 b.p.m. (lenient control), with stricter control for patients with continuing symptoms 1.
• Combination therapy with beta-blockers and digoxin, or beta-blockers and calcium channel blockers, may be used to control heart rate and rhythm, but should be done under specialist advice and monitored with an ambulatory ECG to check for bradycardia 1.

From the Research

Atrial Fibrillation with a Pacemaker

• A pacemaker is used to facilitate medical management of atrial fibrillation with rate control agents and anti-arrhythmic drugs 2.
• Many patients with pacemakers also develop atrial fibrillation, and trials involving pacing at alternative sites or in combination with specific algorithms for prevention of atrial fibrillation have not shown consistent results 3.
• The concept of atrial fibrillation prevention by pacemaker therapy has been introduced in patients with bradycardia-tachycardia syndrome or vagally mediated bradycardia-dependent atrial fibrillation 4.

Incidence of Atrial Fibrillation with a Pacemaker

• The incidence of atrial fibrillation before and after pacemaker implantation has been studied, and it was found that recurrence of atrial fibrillation is not prevented by physiological pacing 5.
• Atrial fibrillation can still occur in patients with a pacemaker, and the incidence of atrial fibrillation in patients with atrial fibrillation is significantly higher than in those without atrial fibrillation 5.
• Pacemaker implantation can improve the quality of life of patients with permanent atrial fibrillation with ventricular arrest, but it does not reduce sudden cardiac death, cardiovascular events, and stroke nor improve the cumulative survival rate 6.

Management of Atrial Fibrillation with a Pacemaker

• Atrioventricular junction ablation in conjunction with pacemaker implantation can be an effective therapy for controlling a rapid ventricular rate during atrial fibrillation 2.
• Cardiac resynchronization therapy devices are likely to be beneficial in select patients with chronic atrial fibrillation 2.
• The combination of drug therapy and pacing is essential for effective atrial fibrillation control 4.