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Pacing therapies for atrial fibrillation

Diane M. Bosen MSN, RN, APRN-BC, CCRN Nursing2011 Critical Care


November 2010
Volume 5 Number 6
Pages 38 - 42
Atrial fibrillation (AF) is the most common sustained dysrhythmia encountered in clinical

practice settings, affecting healthcare costs and patient quality of life, and posing the risk of

death from heart failure or stroke. 1 This article reviews the mechanisms of AF, its clinical

manifestations, and pacing therapies.

Figure. No caption available.


About AF

AF can occur in patients with or without diagnosed heart disease (see Clinical conditions

associated with AF). In AF, numerous areas in the atria are stimulated at different rates, so

depolarization can't occur normally. This disorganized atrial depolarization interrupts normal

atrial mechanical contraction and places the patient at increased risk for thrombus formation and

stroke.

A patient with AF usually has decreased cardiac output because of the loss of synchronous atrial

mechanical activity (atrial kick). The patient may experience signs and symptoms such as chest

discomfort, dyspnea, palpitations, near-syncope or syncope, dizziness or lightheadedness,

fatigue, or orthostatic hypotension. Pulmonary edema secondary to reduced diastolic filling time,

increased myocardial oxygen demands, or functional impairment of the ventricle may be an

initial sign of AF with an uncontrolled ventricular rate (higher than 100 beats/minute).

The treatment priority for AF is rate control rather than rhythm control.2 A poorly controlled

ventricular rate may lead to dilated ventricular cardiomyopathy, also known as tachycardia-

induced cardiomyopathy, with subsequent heart failure.

Pharmacologic therapy is the first-line treatment; multiple drugs may be needed to maximize rate

control. Unfortunately, patients may not achieve rate control if the maximum recommended
dosage of the medication doesn't control the responsiveness of the atrioventricular (AV) node,

and if the patient can't tolerate the medication, doesn't adhere to the medication regimen, can't

afford the medication, or has comorbid conditions that limit therapy. (Patients with chronic

obstructive pulmonary disease [COPD], for example, may not be able to tolerate the beta-

blockers typically used to optimize rate control.)

Setting the pace

For patients who don't achieve ventricular rate control despite optimal medical therapy, and for

patients with an intractable dysrhythmia, atrial pacing can be combined with drug therapy. This

treatment isn't a primary treatment.

The choice of atrial pacemaker depends on the desired outcome, and various pacing protocols are

available to treat AF. Atrial pacing may have an antiarrhythmic effect, whereas ventricular

pacing may be more proarrhythmic.3

Some studies suggest that AF may be initiated by a premature beat or may be the end result of a

bradydysrhythmia. By controlling the atrial rate with pacing, AF may be prevented. The

pacemaker may prevent a bradydysrhythmia or suppress a premature beat through overdrive

pacing-that is, initiating a paced rate that's higher than the patient's intrinsic rate. Patients with an

intrinsic heart rate less than 60 beats/minute are more likely to benefit from pacing therapy to

prevent bradycardia-induced AF.

Different types of atrial pacemakers may be used.

* A single-lead atrial pacemaker is rarely used because other, more effective options are now

available. However, a single-lead pacemaker can be used to directly stimulate the right atrium if

indicated, with the lead positioned in the high right atrium.

* A biatrial pacemaker positions a lead in each atrium and stimulates both simultaneously. This

shortens intra-atrial conduction delays, corrects atrial dyssynchrony, and may reduce the
frequency or degree of conduction blocks. The pacemaker leads may be placed in the high right

atrium and the distal coronary sinus, which indirectly paces the left atrium. Biatrial pacing is

preferred over single-lead atrial pacing, but may not have any benefit over AV sequential pacing

(more on this shortly).3

* A dual-site atrial pacemaker positions two leads in the right atrium. This type of pacemaker is

preferred to single-lead atrial pacing because it's more effective in achieving rate control. The

dual-site pacemaker also reduces left-sided AV delay, resulting in improved atrial filling and

improved atrial kick. When dual-site pacing is used, the leads are positioned near the septum,

near the ostium (opening) of the coronary sinus, or in the area of Bachmann bundle.3

* Dual-chamber pacing or AV sequential pacing paces the right atrium and right ventricle

sequentially, mimicking normal cardiac physiology and preserving atrial kick. AV sequential

pacing also can reduce the frequency and degree of conduction blocks.4

* Right ventricular pacing. Some studies suggest that ventricular pacing alone may be

detrimental because the loss of atrial kick may produce negative hemodynamic effects.5 Also

ventricular pacing alone may predispose the patient to AF. Right ventricular pacing has been

shown to increase the risk of death or exacerbate heart failure in patients who have left

ventricular systolic dysfunction (that is, an ejection fraction less than 35%). Right ventricular

pacing also can worsen mitral regurgitation in patients with valvular disease.5

Atrial pacing also may be used to terminate an atrial tachycardia that could deteriorate to AF.

Therapies include atrial overdrive pacing and an implantable atrial cardioverter defibrillator.

Atrial overdrive pacing paces the atrium at a rate higher than the patient's intrinsic rate, then

gradually decreases the pacing rate. Because the atrial rate can reach well over 200 beats/minute

without pharmacologic therapy, atrial overdrive pacing is used in combination with drug therapy.
However, this type of therapy may not be well tolerated by patients because the increased heart

rates pose the risk of hypotension and syncope.2

An implantableatrial cardioverter defibrillator may be used alone or in conjunction with

ventricular defibrillation. When an atrial defibrillator is used, two atrial defibrillation leads are

used: one coil is placed in the right atrium and the other in the distal coronary sinus. Tiered

shock therapy can be delivered with moderate discomfort to the patient, so the use of this therapy

is limited. Generally one to two shocks are needed to convert AF into normal sinus rhythm.

Complications associated with device implantation include surgical-site infection and bleeding.

This treatment is indicated for patients who can't tolerate pharmacologic therapy, and who aren't

candidates for ablation or in whom ablation wasn't effective.3

Ablate and pace

Radiofrequency ablation of the AV node and implantation of a permanent pacemaker, a

technique known as "ablate and pace," may be used in patients who aren't candidates for curative

procedures such as surgical ablation. This therapy also may be used in the 10% of patients with

AF who are severely symptomatic and either are intolerant or fail to respond to pharmacologic

therapy, or have a refractory dysrhythmia.

The ablate and pace procedure leaves the patient fully dependent on the pacemaker. However, if

a rate-responsive pacemaker is used, the patient's heart rate will adjust to accommodate exercise

or increased respiratory effort as well as periods of rest.

Another advantage of the ablate and pace procedure is that the patient's cardiac output and

cardiac performance are optimized (and therefore quality of life improved) without the adverse

effects of drug therapy. The patient may have improved exercise tolerance, and because no long-

term drug therapy is needed, the procedure is cost-effective. Compared to other atrial pacing
therapies, ablate and pace is easy to perform and less likely to cause complications. Although not

a cure for AF, it is palliative therapy.2

Biventricular pacing has been shown to be more effective than right ventricular pacing alone

with the ablate and pace strategy, and is the preferred pacing modality for patients who've

undergone AV node ablation.6

Caring for your patient

If pacing is used for AF, monitor your patient's response to therapy and assess his cardiac rhythm

for appropriate pacemaker sensing and capture depending on the type of pacing used.

Notify the patient's healthcare provider if the patient develops recurrent AF or the pacemaker

doesn't function properly.

If your patient had AV node ablation and the pacemaker fails to capture, be prepared to perform

CPR and initiate transcutaneous pacing.

Patients with AF requiring pacing therapies may need anticoagulation therapy. Teach patients

about anticoagulation, including the need for frequent monitoring (prothrombin time and

international normalized ratio), signs and symptoms of bleeding and stroke, and when to contact

a healthcare provider.2

By understanding the types of atrial pacing, you can help your patient deal with this common

dysrhythmia.

Clinical conditions associated with AF

Cardiovascular

* systemic hypertension

* coronary artery disease (especially of the right coronary artery)

* heart failure

* pericarditis
* myocarditis

* valvular heart disease (especially mitral)

* cardiac surgery

* left atrial enlargement

* rheumatic heart disease

* congenital heart disease

* sick sinus syndrome

* Wolff-Parkinson-White syndrome

* degeneration of the conduction system

* cardiomyopathy

Noncardiac

* electrolyte imbalances

* hyperthyroidism

* acute alcohol intoxication

* parasympathetic (vagal) or sympathetic nervous system imbalances

* pulmonary disease such as COPD

* septic or febrile illness

* obesity

* toxins including cocaine and caffeine

* genetic predisposition

* advanced age

* diabetes

* stress

* electrocution
* pulmonary embolism

* idiopathic

REFERENCES

1. Josephson ME. Clinical Cardiac Electrophysiology. 4th ed. Philadelphia, PA: Wolters Kluwer

Health; 2008. [Context Link]

2. Natale A, ed. Handbook of Cardiac Electrophysiology. London, UK: Informa Healthcare;

2008. [Context Link]

3. Ellenbogen KA, Wilkoff BL, Kay GN, Lau CP. Clinical Cardiac Pacing, Defibrillation, and

Resynchronization Therapy. 3rd ed. Philadelphia, PA: Elsevier Saunders; 2007. [Context Link]

4. Fogoros RN. Electrophysiology Testing. 4th ed. Malden, MA: Blackwell Publishing;

2006. [Context Link]

5. Zipes DP, Jalife J. Cardiac Electrophysiology, From Cell to Bedside. 5th ed. Philadelphia, PA:

Elsevier Saunders; 2009. [Context Link]

6. Doshi RN, Daoud EG, Fellows C, et al. Left ventricular-based cardiac stimulation post AV

nodal ablation evaluation (the PAVE study). J Cardiovasc Electrophysiol. 2005;16(11):1160-

1165. [Context Link]