From the Guidelines
A pacemaker is recommended for patients with atrial fibrillation (AF) who experience symptomatic heart pauses, as it can significantly improve morbidity, mortality, and quality of life. When considering pacemaker implantation in patients with AF, it is essential to evaluate the frequency and duration of pauses, associated symptoms, and underlying heart conditions. According to the 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities 1, the choice of pacemaker generator depends on various factors, including the presence of atrioventricular block, carotid sinus hypersensitivity, and the need for rate response.
Key considerations for pacemaker implantation in AF patients include:
- Symptomatic heart pauses lasting longer than 3-5 seconds
- Associated symptoms such as dizziness, fainting, or fatigue
- Underlying heart conditions, such as atrioventricular block or sinus node dysfunction
- Overall health status and potential benefits of pacemaker therapy
In patients with AF and symptomatic heart pauses, a dual-chamber pacemaker with mode-switching capability may be the most suitable option, as it allows for atrioventricular synchrony during pacing and can adapt to changes in heart rhythm 1. The procedure involves placing a small electronic device under the skin of the chest or abdomen, with thin wires (leads) connecting to the heart chambers. The pacemaker then monitors the heart rhythm and sends electrical impulses when needed to maintain an appropriate heart rate. By prioritizing the most recent and highest quality study, we can ensure that patients with AF and symptomatic heart pauses receive the most effective and evidence-based treatment, ultimately improving their morbidity, mortality, and quality of life.
From the Research
Indications for Pacemaker Implantation in Atrial Fibrillation
- Symptomatic prolonged sinus pauses on termination of atrial fibrillation (AF) are an accepted indication for pacemaker implantation 2, 3, 4
- Pacing is indicated in patients with AF when clinical symptoms are readily attributable to slow ventricular rate and prolonged ventricular pauses 3
Role of Catheter Ablation in Patients with Paroxysmal Atrial Fibrillation and Prolonged Sinus Pauses
- Catheter ablation has been reported to be a curative therapy for tachycardia-bradycardia syndrome without pacemaker implantation 2, 5
- Successful ablation can eliminate both AF and prolonged sinus pauses in the majority of patients with tachycardia-bradycardia syndrome 5
- AF ablation seems to be superior to a strategy of pacing plus antiarrhythmic drugs in patients with paroxysmal AF-related tachycardia-bradycardia syndrome 2
Prognosis of Prolonged Ventricular Pauses in Atrial Fibrillation
- Prolonged ventricular pauses in AF are not a marker of poor prognosis in terms of mortality 6
- However, pauses in patients referred to Holter due to syncope and/or dizzy spells are associated with an increased risk of pacemaker treatment 6