From the Guidelines
In an emergency setting, a patient with atrial fibrillation and a pacemaker should be treated with rate control as the initial therapy, using beta-blockers, diltiazem, verapamil, or digoxin, depending on the left ventricular ejection fraction (LVEF), as recommended by the 2024 ESC guidelines 1. The choice of rate control medication should consider the patient's LVEF, with beta-blockers, diltiazem, verapamil, or digoxin recommended for patients with LVEF >40% 1.
- For patients with LVEF ≤40%, beta-blockers and/or digoxin are recommended 1.
- Intravenous amiodarone, digoxin, esmolol, or landiolol may be considered in patients with hemodynamic instability or severely depressed LVEF 1. The pacemaker should be interrogated immediately to ensure proper functioning and to rule out pacemaker-mediated tachycardia.
- Anticoagulation should be initiated promptly, considering the patient's CHA₂DS₂-VASc score, with heparin or low molecular weight heparin, followed by oral anticoagulants like warfarin, apixaban, or rivaroxaban, as suggested by the 2018 Chest guideline 1. If the AF is causing hemodynamic instability despite the presence of a pacemaker, synchronized cardioversion may be necessary, with precautions taken to avoid interfering with the pacemaker function, as recommended by the 2024 ESC guidelines 1.
- The management of AF in patients with a pacemaker requires careful consideration of device-arrhythmia interactions, making a cardiology consultation essential for comprehensive care.
From the Research
Emergency Treatment for Atrial Fibrillation in a Patient with a Pacemaker
The emergency treatment for atrial fibrillation (AF) in a patient with a permanent artificial cardiac pacemaker involves several considerations, including:
- Assessing patient clinical stability and evaluating and treating reversible causes 2
- Immediate cardioversion is indicated in the hemodynamically unstable patient 2
- Rate or rhythm control are options for management of AF in hemodynamically stable patients 2
- Intravenous beta blockers, diltiazem, or verapamil may be administered to slow immediately a very rapid ventricular rate in AF 3, 4
- A permanent pacemaker should be implanted in patients with AF and symptoms such as dizziness or syncope associated with ventricular pauses greater than 3 seconds which are not drug-induced 3, 4
Considerations for Patients with a Pacemaker
- Paroxysmal AF associated with the tachycardia-bradycardia syndrome should be treated with a permanent pacemaker in combination with drugs 3, 4
- Nondrug therapies should be performed in patients with symptomatic AF in whom a rapid ventricular rate cannot be slowed by drug therapy 3, 4
- Elective DC cardioversion has a higher success rate and a lower incidence of cardiac adverse effects than does medical cardioversion in converting AF to sinus rhythm 3
- Unless transesophageal echocardiography has shown no thrombus in the left atrial appendage before cardioversion, oral warfarin should be given for 3 weeks before elective DC or drug cardioversion of AF and continued for at least 4 weeks after maintenance of sinus rhythm 3, 4
Anticoagulation Therapy
- Patients with chronic or paroxysmal AF at high risk for stroke should be treated with long-term warfarin to achieve an International Normalized Ratio of 2.0 to 3.0 3, 4
- Patients with AF at low risk for stroke or with contraindications to warfarin should be treated with aspirin 325 mg daily 3, 4
- Direct oral anticoagulants are a safe and reliable option for anticoagulation 2