From the Guidelines
Yes, atrial fibrillation (AFib) can coexist with a pacemaker, and treatment typically involves a combination of the pacemaker for bradycardia management, medications to control AFib, and potentially blood thinners to prevent stroke. Pacemakers are primarily designed to treat slow heart rhythms (bradycardia) and don't necessarily prevent or treat AFib, which is a rapid, irregular heart rhythm originating in the atria. Many patients with pacemakers continue to experience AFib episodes because standard pacemakers don't suppress the abnormal electrical signals that cause AFib. However, certain advanced pacemakers with specific programming can help manage AFib symptoms, as recommended by the 2024 ESC guidelines for the management of atrial fibrillation 1.
Key Considerations
- For patients with both AFib and a pacemaker, treatment may include medications like beta-blockers, calcium channel blockers, or antiarrhythmic drugs to control the AFib, as outlined in the 2024 ESC guidelines 1.
- Some patients may also require blood thinners like warfarin, apixaban, rivaroxaban, or dabigatran to prevent stroke, as part of the AF-CARE approach which includes comorbidity and risk factor management, avoiding stroke and thromboembolism, reducing symptoms by rate and rhythm control, and evaluation and dynamic reassessment 1.
- In certain cases, specialized pacemakers with atrial overdrive pacing capabilities might help reduce AFib episodes by delivering rapid pacing to suppress abnormal rhythms.
- If AFib becomes problematic despite having a pacemaker, additional procedures like catheter ablation might be considered to target the abnormal electrical pathways causing the AFib, as recommended by the 2024 ESC guidelines 1.
Treatment Approach
- The treatment approach for patients with AFib and a pacemaker should be individualized, taking into account the patient's symptoms, left ventricular ejection fraction (LVEF), and other comorbidities, as outlined in the 2024 ESC guidelines 1.
- Atrioventricular node ablation in combination with pacemaker implantation may be considered in patients unresponsive to, or ineligible for, intensive rate and rhythm control therapy, as recommended by the 2024 ESC guidelines 1.
- The goal of treatment is to control symptoms, reduce the risk of stroke and thromboembolism, and improve quality of life, as emphasized in the AF-CARE approach 1.
From the Research
Atrial Fibrillation and Pacemakers
- Atrial fibrillation (AFib) can coexist with a pacemaker, as pacemakers have an important role in the management of patients with AFib, particularly in rate control and rhythm control 2.
- Many patients with pacemakers also develop AFib, and the use of pacemakers impacts the largest number of patients with AFib 3.
- The incidence of AFib in patients with pacemakers can be significant, with one study showing that 8.9% of patients developed AFib before pacemaker implantation, and 8.1% developed AFib after implantation 4.
Management of AFib with Pacemakers
- Pacemakers can be used to facilitate medical management of AFib with rate control agents and anti-arrhythmic drugs 2.
- Atrioventricular junction ablation in conjunction with pacemaker implantation can be an effective therapy for controlling a rapid ventricular rate during AFib 2, 5.
- Cardiac resynchronization therapy devices may be beneficial in select patients with chronic AFib 2.
- AFib ablation may be a superior treatment option to pacing plus antiarrhythmic drugs in patients with paroxysmal AF-related tachycardia-bradycardia syndrome 6.