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  • Review Article
  • Published:

Management of atrial fibrillation in bradyarrhythmias

Nature Reviews Cardiology volume 12, pages 337–349 (2015)Cite this article

Subjects

Key Points

  • Sinus node disease (SND), a common indication to implant a pacemaker, is associated with atrial tachyarrhythmias, specifically atrial fibrillation (AF), present either at implantation or detected subsequently

  • Device-detected atrial tachyarrhythmias, even if short (5–6 min) and asymptomatic, are associated with an increased risk of stroke

  • The choice of pacing modality is clinically important, because physiological pacing (for example, maintaining atrio–ventricular synchrony) is superior to single-chamber ventricular pacing for prevention of AF in SND

  • Atrial tachyarrhythmias and evolution of AF towards persistent or permanent AF can be reduced by implanting DDDR pacemakers with algorithms to address antitachycardia pacing and minimize unnecessary right ventricular pacing

Abstract

Sinus node disease (SND), a common indication to implant a pacemaker, is frequently associated with atrial fibrillation (AF), either at implantation (paroxysmal AF) or during follow-up, which often evolves to persistent or permanent AF. Pacemakers with an atrial lead allow continuous monitoring of the atrial rhythm and enable detection of the burden of AF. Asymptomatic atrial tachyarrhythmias, being associated with increased risk of stroke, have important prognostic implications, and their detection could guide decision-making about antithrombotic prophylaxis. Pacing mode and pacing algorithms can influence the occurrence of AF and atrial tachyarrhythmias. In DDD/DDDR pacing mode, reduction of unnecessary right ventricular pacing positively affects the occurrence and evolution of AF, but patients with a history of atrial tachyarrhythmias maintain an increased risk of arrhythmic events. In the MINERVA study, the use of algorithms that act in the atrium for preventive pacing and atrial antitachycardia pacing while minimizing right ventricular pacing was beneficial in patients with SND and previous atrial tachyarrhythmias, and was associated with a significant reduction in evolution to permanent AF. New information available on therapies delivered at the atrial level by implanted devices suggests clinical advantages that could improve current guidelines for the management of AF and atrial tachyarrhythmias.

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Figure 1: Dual-chamber (DDD) pacemaker, with one bipolar lead in the right atrial appendage (1) and one bipolar lead at the apex of the right ventricle (2).
Figure 2: Remote transmission of diagnostic data from an implanted device.
Figure 3: Results of the MINERVA trial.69
Figure 4: Effective interruption of an atrial tachyarrhythmia in a patient with a Medtronic DDDR pacemaker implanted for sinus node disease.

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Acknowledgements

The authors thank A. Grammatico (Medtronic, Rome, Italy) for his important contribution in collecting all the literature on the discussed topics and for help in planning and completing the MINERVA study.

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Authors and Affiliations

  1. Department of Experimental, Institute of Cardiology, Diagnostic and Specialty Medicine, University of Bologna, S. Orsola-Malpighi University Hospital, Via Massarenti 9, Bologna, 40138, Italy

    Giuseppe Boriani

  2. Institute of Internal Medicine and Cardiology, University of Florence, Viale Morgagni 85, Florence, 50134, Italy

    Luigi Padeletti

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  1. Giuseppe Boriani
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Correspondence to Giuseppe Boriani.

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Competing interests

G.B. received modest speaker fees from Boston Scientific and Medtronic. L.P. received modest research grants and consultant or advisory board grants from Boston Scientific, Medtronic, and St. Jude Medical.

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Boriani, G., Padeletti, L. Management of atrial fibrillation in bradyarrhythmias. Nat Rev Cardiol 12, 337–349 (2015). https://doi.org/10.1038/nrcardio.2015.30

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