Atrial pacing for the prevention and termination of atrial fibrillation

Atrial fibrillation (AF) affects about 2% of the general population and 8%-11% of those older than 65 years. The demand for effective therapeutic strategies for AF is anticipated to increase substantially as the proportion of the elderly population increases. Atrioventricular nodal ablation accompanied by permanent pacemaker implantation is an established option in elderly patients with intractable arrhythmia and poor ventricular rate control. However, it renders most patients pacemaker dependent and does not eliminate symptoms associated with loss of atrial transport or reduce the risk of stroke. The considerable limitations of rhythm or rate control strategies prompted interest in preventative atrial pacing, which may reduce the incidence of AF by either eliminating the triggers and/or by modifying the substrate of AF. Atrial or dual-chamber pacing has been proven to prevent or delay progression to permanent AF in elderly patients with sinus node dysfunction as compared with ventricular pacing. Patients with advanced atrial conduction delay may benefit from atrial resynchronization pacing. There may be additional benefits associated with the use of particular sites of pacing, specific pacing algorithms designed to target potential triggers of AF, and pace-termination of atrial tachycardia. Preventive and antitachycardia pacing algorithms incorporated in implantable cardioverter-defibrillators and pacemakers are currently under investigation and may offer a valuable alternative to antiarrhythmic drug therapy in elderly patients with left ventricular dysfunction at high risk of proarrhythmia or worsening heart failure. The evolution of hybrid therapy, in which two or more different strategies are employed in the same patient, may be the most effective approach to management of AF.