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The role of pacemakers in the prevention of atrial fibrillation

Rod Passman, MD, MSCE
Section Editor
Bradley P Knight, MD, FACC
Deputy Editor
Gordon M Saperia, MD, FACC


The principal reason to place a pacemaker in a patient with atrial fibrillation (AF) is to treat symptomatic bradycardia. Pacing has not been shown to prevent the development of AF.

This topic will review the role of pacemakers in the prevention of AF. Brief mention will be given to implantable cardioverter defibrillators. The utility of other nonpharmacologic strategies for preventing AF is discussed separately. (See "Catheter ablation to prevent recurrent atrial fibrillation: Clinical applications" and "Surgical approaches to prevent recurrent atrial fibrillation".)


In patients with a history of atrial fibrillation (AF), pacing from one or both atria has been suggested as a means to reduce AF recurrences. There is no conclusive evidence to support the implantation of an atrial pacemaker to prevent AF in patients who do not have an indication for pacing; symptomatic bradycardia is the most important group [1]. Similar to societal guidelines, we do not recommend the insertion of an atrial pacemaker for this purpose [2]. (See 'Overdrive (antitachycardia) atrial pacing' below.)


Many patients with atrial fibrillation (AF) have sick sinus syndrome with symptomatic bradycardia requiring pacemaker placement. The appropriate pacing modes for patients with sick sinus syndrome are discussed separately. (See "Treatment of the sick sinus syndrome", section on 'Treatment'.)

In patients who require permanent pacing, only physiologic pacing from the right atrium has been shown to prevent episodes of AF.


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Literature review current through: Sep 2015. | This topic last updated: Aug 31, 2015.
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  1. Ellenbogen KA. Pacing therapy for prevention of atrial fibrillation. Heart Rhythm 2007; 4:S84.
  2. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2014; 64:e1.
  3. Bruce GK, Friedman PA. Device-based therapies for atrial fibrillation. Curr Treat Options Cardiovasc Med 2005; 7:359.
  4. Sparks PB, Mond HG, Vohra JK, et al. Electrical remodeling of the atria following loss of atrioventricular synchrony: a long-term study in humans. Circulation 1999; 100:1894.
  5. Sparks PB, Mond HG, Vohra JK, et al. Mechanical remodeling of the left atrium after loss of atrioventricular synchrony. A long-term study in humans. Circulation 1999; 100:1714.
  6. Nielsen JC, Andersen HR, Thomsen PE, et al. Heart failure and echocardiographic changes during long-term follow-up of patients with sick sinus syndrome randomized to single-chamber atrial or ventricular pacing. Circulation 1998; 97:987.
  7. Satoh T, Zipes DP. Unequal atrial stretch in dogs increases dispersion of refractoriness conducive to developing atrial fibrillation. J Cardiovasc Electrophysiol 1996; 7:833.
  8. Waktare JE, Hnatkova K, Sopher SM, et al. The role of atrial ectopics in initiating paroxysmal atrial fibrillation. Eur Heart J 2001; 22:333.
  9. Prakash A, Delfaut P, Krol RB, Saksena S. Regional right and left atrial activation patterns during single- and dual-site atrial pacing in patients with atrial fibrillation. Am J Cardiol 1998; 82:1197.
  10. Healey JS, Toff WD, Lamas GA, et al. Cardiovascular outcomes with atrial-based pacing compared with ventricular pacing: meta-analysis of randomized trials, using individual patient data. Circulation 2006; 114:11.
  11. Connolly SJ, Kerr CR, Gent M, et al. Effects of physiologic pacing versus ventricular pacing on the risk of stroke and death due to cardiovascular causes. Canadian Trial of Physiologic Pacing Investigators. N Engl J Med 2000; 342:1385.
  12. Skanes AC, Krahn AD, Yee R, et al. Progression to chronic atrial fibrillation after pacing: the Canadian Trial of Physiologic Pacing. CTOPP Investigators. J Am Coll Cardiol 2001; 38:167.
  13. Lamas GA, Lee KL, Sweeney MO, et al. Ventricular pacing or dual-chamber pacing for sinus-node dysfunction. N Engl J Med 2002; 346:1854.
  14. Sweeney MO, Hellkamp AS, Ellenbogen KA, et al. Adverse effect of ventricular pacing on heart failure and atrial fibrillation among patients with normal baseline QRS duration in a clinical trial of pacemaker therapy for sinus node dysfunction. Circulation 2003; 107:2932.
  15. Sweeney MO, Bank AJ, Nsah E, et al. Minimizing ventricular pacing to reduce atrial fibrillation in sinus-node disease. N Engl J Med 2007; 357:1000.
  16. Andersen HR, Thuesen L, Bagger JP, et al. Prospective randomised trial of atrial versus ventricular pacing in sick-sinus syndrome. Lancet 1994; 344:1523.
  17. Andersen HR, Nielsen JC, Thomsen PE, et al. Long-term follow-up of patients from a randomised trial of atrial versus ventricular pacing for sick-sinus syndrome. Lancet 1997; 350:1210.
  18. Kristensen L, Nielsen JC, Mortensen PT, et al. Incidence of atrial fibrillation and thromboembolism in a randomised trial of atrial versus dual chamber pacing in 177 patients with sick sinus syndrome. Heart 2004; 90:661.
  19. Nielsen JC, Kristensen L, Andersen HR, et al. A randomized comparison of atrial and dual-chamber pacing in 177 consecutive patients with sick sinus syndrome: echocardiographic and clinical outcome. J Am Coll Cardiol 2003; 42:614.
  20. Stambler BS, Ellenbogen KA, Orav EJ, et al. Predictors and clinical impact of atrial fibrillation after pacemaker implantation in elderly patients treated with dual chamber versus ventricular pacing. Pacing Clin Electrophysiol 2003; 26:2000.
  21. Cooper JM, Katcher MS, Orlov MV. Implantable devices for the treatment of atrial fibrillation. N Engl J Med 2002; 346:2062.
  22. Saksena S, Prakash A, Ziegler P, et al. Improved suppression of recurrent atrial fibrillation with dual-site right atrial pacing and antiarrhythmic drug therapy. J Am Coll Cardiol 2002; 40:1140.
  23. Delfaut P, Saksena S, Prakash A, Krol RB. Long-term outcome of patients with drug-refractory atrial flutter and fibrillation after single- and dual-site right atrial pacing for arrhythmia prevention. J Am Coll Cardiol 1998; 32:1900.
  24. Levy T, Walker S, Rex S, et al. No incremental benefit of multisite atrial pacing compared with right atrial pacing in patients with drug refractory paroxysmal atrial fibrillation. Heart 2001; 85:48.
  25. Lau CP, Tse HF, Yu CM, et al. Dual-site atrial pacing for atrial fibrillation in patients without bradycardia. Am J Cardiol 2001; 88:371.
  26. Leclercq JF, De Sisti A, Fiorello P, et al. Is dual site better than single site atrial pacing in the prevention of atrial fibrillation? Pacing Clin Electrophysiol 2000; 23:2101.
  27. Spitzer SG, Wacker P, Gazarek S, et al. Primary prevention of atrial fibrillation: does the atrial lead position influence the incidence of atrial arrhythmias in patients with sinus node dysfunction? Results from the PASTA Trial. Pacing Clin Electrophysiol 2009; 32:1553.
  28. Lau CP, Tachapong N, Wang CC, et al. Prospective randomized study to assess the efficacy of site and rate of atrial pacing on long-term progression of atrial fibrillation in sick sinus syndrome: Septal Pacing for Atrial Fibrillation Suppression Evaluation (SAFE) Study. Circulation 2013; 128:687.
  29. Israel CW, Lawo T, Lemke B, et al. Atrial pacing in the prevention of paroxysmal atrial fibrillation: first results of a new combined algorithm. Pacing Clin Electrophysiol 2000; 23:1888.
  30. Funck RC, Adamec R, Lurje L, et al. Atrial overdriving is beneficial in patients with atrial arrhythmias: first results of the PROVE Study. Pacing Clin Electrophysiol 2000; 23:1891.
  31. Carlson MD, Ip J, Messenger J, et al. A new pacemaker algorithm for the treatment of atrial fibrillation: results of the Atrial Dynamic Overdrive Pacing Trial (ADOPT). J Am Coll Cardiol 2003; 42:627.
  32. Wiberg S, Lönnerholm S, Jensen SM, et al. Effect of right atrial overdrive pacing in the prevention of symptomatic paroxysmal atrial fibrillation: a multicenter randomized study, the PAF-PACE study. Pacing Clin Electrophysiol 2003; 26:1841.
  33. Mont L, Ruiz-Granell R, Martínez JG, et al. Impact of anti-tachycardia pacing on atrial fibrillation burden when added on top of preventive pacing algorithms: results of the prevention or termination (POT) trial. Europace 2008; 10:28.
  34. Gold MR, Adler S, Fauchier L, et al. Impact of atrial prevention pacing on atrial fibrillation burden: primary results of the Study of Atrial Fibrillation Reduction (SAFARI) trial. Heart Rhythm 2009; 6:295.
  35. Healey JS, Connolly SJ, Gold MR, et al. Subclinical atrial fibrillation and the risk of stroke. N Engl J Med 2012; 366:120.
  36. Boriani G, Tukkie R, Manolis AS, et al. Atrial antitachycardia pacing and managed ventricular pacing in bradycardia patients with paroxysmal or persistent atrial tachyarrhythmias: the MINERVA randomized multicentre international trial. Eur Heart J 2014; 35:2352.
  37. Tracy CM, Epstein AE, Darbar D, et al. 2012 ACCF/AHA/HRS focused update of the 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. [corrected]. Circulation 2012; 126:1784.