The role of pacemakers in the prevention of atrial fibrillation
- Rod Passman, MD, MSCE
Rod Passman, MD, MSCE
- Professor of Medicine
- Northwestern University Feinberg School of Medicine
There has been extensive interest in using pacing mode and specialized pacing algorithms to prevent atrial fibrillation (AF). There are two issues to consider with regard to pacemakers and AF prevention. First, in patients without permanent AF who require pacemakers for a bradycardia indication, maintenance of atrioventricular synchrony (ie, physiologic pacing) is associated with a reduced incidence of AF . Second, in patients with a history of AF, atrial pacing has been suggested as a means to reduce AF recurrences, particularly with novel pacing strategies (dual-site atrial pacing, overdrive atrial pacing).
The data evaluating the efficacy of pacing to prevent AF will be reviewed here. The utility of other nonpharmacologic strategies for preventing AF are discussed separately. (See "Catheter ablation to prevent recurrent atrial fibrillation: Clinical application" and "Surgical approaches to prevent recurrent atrial fibrillation" and "General principles of the implantable cardioverter-defibrillator", section on 'Atrial defibrillation'.)
PHYSIOLOGIC PACING IN PATIENTS REQUIRING PACING
Isolated right ventricular (RV) pacing disrupts the normal sequence of activation of the atria and ventricles in patients in normal sinus rhythm. The failure to activate the atria before the ventricles with RV pacing is termed atrioventricular (AV) dyssynchrony and may promote atrial fibrillation (AF). In addition, RV pacing causes the right ventricle to contract before the left ventricle (LV) and causes the septum to contract before the lateral wall of the LV, simulating the effects of left bundle branch block. This phenomenon is referred to as ventricular dyssynchrony or asynchrony and can also lead to AF. This risk can be reduced by maintaining AV synchrony and by minimizing the amount of ventricular pacing. (See "Modes of cardiac pacing: Nomenclature and selection", section on 'Physiologic pacing' and "Modes of cardiac pacing: Nomenclature and selection", section on 'Modes to minimize ventricular pacing'.)
The term "physiologic pacing" has historically been used to describe the maintenance of AV synchrony. However, it can also encompass maintenance of ventricular synchrony. The benefit of physiologic modes of pacing on the development of AF has been demonstrated in a number of clinical trials [2-12]. The following discussion will review the results from a meta-analysis and the three largest trials: CTOPP, MOST, and SAVE PACe.
Mechanisms — Several mechanisms may contribute to the benefit of physiologic pacing in preventing AF in patients who are treated with standard-chamber dual-chamber pacing. (See "The electrocardiogram in atrial fibrillation".)
- Bruce GK, Friedman PA. Device-based therapies for atrial fibrillation. Curr Treat Options Cardiovasc Med 2005; 7:359.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- Andersen HR, Thuesen L, Bagger JP, et al. Prospective randomised trial of atrial versus ventricular pacing in sick-sinus syndrome. Lancet 1994; 344:1523.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- Satoh T, Zipes DP. Unequal atrial stretch in dogs increases dispersion of refractoriness conducive to developing atrial fibrillation. J Cardiovasc Electrophysiol 1996; 7:833.
- Waktare JE, Hnatkova K, Sopher SM, et al. The role of atrial ectopics in initiating paroxysmal atrial fibrillation. Eur Heart J 2001; 22:333.
- 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.
- Wang NC, Passman R, Goldberger JJ. Minimizing ventricular pacing in sinus-node disease. N Engl J Med 2007; 357:2733.
- Padeletti L. Does DDD pacing with minimized ventricular stimulation prevent atrial fibrillation in sinus-node disease? Nat Clin Pract Cardiovasc Med 2008; 5:190.
- Cooper JM, Katcher MS, Orlov MV. Implantable devices for the treatment of atrial fibrillation. N Engl J Med 2002; 346:2062.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Circulation 2008; 117:e350.
- Crystal E, Connolly SJ, Sleik K, et al. Interventions on prevention of postoperative atrial fibrillation in patients undergoing heart surgery: a meta-analysis. Circulation 2002; 106:75.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- PHYSIOLOGIC PACING IN PATIENTS REQUIRING PACING
- CLINICAL TRIAL EVIDENCE
- CTOPP trial
- MOST trial
- SAVE PACe trial
- ATRIAL PACING TO PREVENT RECURRENT AF
- Dual-site right atrial and biatrial pacing
- Impact of site and rate of atrial pacing
- Overdrive (antitachycardia) atrial pacing
- - POT trial
- MAJOR SOCIETY GUIDELINES
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS