What is the best treatment approach for patients with runs of atrial fibrillation (AF) detected on pacemaker check?

Management of Runs of Atrial Fibrillation Detected on Pacemaker Check

For patients with runs of atrial fibrillation detected on pacemaker check, a rate control strategy with beta-blockers, diltiazem, verapamil, or digoxin is recommended as first-line therapy, along with appropriate anticoagulation based on stroke risk assessment. 1

Initial Assessment

When runs of atrial fibrillation (AF) are detected on pacemaker interrogation, the following factors should be evaluated:

• Duration and frequency of AF episodes
• Ventricular rate during episodes
• Symptoms associated with episodes (if any)
• Patient's stroke risk using CHA₂DS₂-VASc score
• Presence of structural heart disease
• Left ventricular ejection fraction (LVEF)

Rate Control Strategy

Rate control is the recommended initial approach for most patients with AF detected on pacemaker check 1:

• For patients with LVEF >40%:

  • First-line: Beta-blockers, diltiazem, verapamil, or digoxin 1
  • Target heart rate: <110 bpm at rest (lenient control), with stricter control for persistent symptoms 1

• For patients with LVEF ≤40%:

  • First-line: Beta-blockers or digoxin 1
  • Avoid non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to negative inotropic effects 2

• For severely symptomatic patients with permanent AF and heart failure hospitalization:

  • Consider AV node ablation with cardiac resynchronization therapy 1

Anticoagulation Strategy

Anticoagulation should be guided by the patient's CHA₂DS₂-VASc score, regardless of whether AF is paroxysmal or persistent 1, 2:

• Direct oral anticoagulants (DOACs) are recommended in preference to vitamin K antagonists (VKAs) 1
• Even short episodes of AF detected on pacemaker can increase stroke risk 3
• The recent ARTESIA trial showed that in patients with subclinical AF (6 minutes to 24 hours), apixaban reduced stroke risk compared to aspirin (0.78% vs 1.24% per year), though with increased bleeding risk 3

Rhythm Control Considerations

While rate control is often the initial strategy, rhythm control may be considered in specific situations:

• For symptomatic patients with persistent AF 1
• Within 12 months of diagnosis in selected patients at risk of thromboembolic events 1
• For patients with AF-related bradycardia or sinus pauses on AF termination 1

Monitoring and Follow-up

• Regular pacemaker checks to monitor AF burden, duration, and frequency
• Assessment of rate control efficacy
• Evaluation of symptoms
• Monitoring for medication side effects
• Periodic reassessment of stroke risk and bleeding risk

Special Considerations

• Pacemaker patients with AF: The pacemaker itself can be programmed to help manage the AF by:

  • Rate smoothing algorithms to reduce irregular ventricular response
  • Atrial overdrive pacing to potentially reduce AF episodes
  • Using pacemaker diagnostics to assess AF burden and guide therapy

• Pitfalls to avoid:

  • Don't confuse atrial oversensing with true AF episodes
  • Don't initiate antiarrhythmic drugs in patients with advanced conduction disturbances unless antibradycardia pacing is provided 1
  • Don't underestimate stroke risk in patients with brief episodes of AF detected only on device interrogation 3

Algorithm for Management

1. Confirm true AF (not oversensing)
2. Assess stroke risk using CHA₂DS₂-VASc score
3. Initiate anticoagulation if CHA₂DS₂-VASc ≥2 in men or ≥3 in women
4. Assess LVEF to guide rate control medication selection
5. Initiate rate control therapy based on LVEF
6. Consider rhythm control if patient remains symptomatic despite rate control
7. Regular monitoring through pacemaker interrogation and clinical assessment

By following this approach, patients with runs of AF detected on pacemaker check can receive appropriate management to reduce symptoms and prevent complications such as stroke, heart failure exacerbation, and mortality.