Current Cardiology Reports

, 21:127 | Cite as

Programming Pacemakers to Reduce and Terminate Atrial Fibrillation

  • Margarida Pujol-López
  • Rodolfo San Antonio
  • José María Tolosana
  • Lluís MontEmail author
Invasive Electrophysiology and Pacing (EK Heist, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Invasive Electrophysiology and Pacing


Purpose of Review

The goal of this paper is to review present knowledge regarding preventive and antitachycardia pacing algorithms, aimed to reduce atrial fibrillation (AF) burden in patients when pacing is indicated.

Recent Findings

Reactive antitachycardia pacing (ATP), the new generation of ATP, is significantly associated with a reduced risk of AF. In patients with indication for pacing and history of AF, pacemakers endowed with atrial preventive pacing and atrial ATP combined with managed ventricular pacing proved superior to standard dual-chamber pacing. Managed ventricular pacing is an algorithm that minimizes unnecessary right ventricular pacing. Progression to persistent AF is prevented by ventricular pacing minimization in patients with normal PR interval.


The synergistic effect of pacemakers that combine atrial preventive pacing with reactive ATP and with algorithms that minimize ventricular pacing can reduce AF incidence and decrease the combined endpoint of permanent AF, hospital admissions, and mortality.


Atrial fibrillation Atrial pacing therapies Antitachycardia pacing Pacing minimization algorithms 



atrial fibrillation




atrial tachycardia


antitachycardia pacing


dual-chamber pacemaker with atrial preventive pacing + atrial antitachycardia pacing


immediate reinitiation of atrial fibrillation


managed ventricular pacing


premature atrial complex



The authors thank Elaine Lilly, for manuscript editing, and Neus Portella for administrative and editing support.

Compliance with Ethical Standards

Conflict of Interest

Margarida Pujol-López and Rodolfo San Antonio declare that they have no conflict of interest in relation to the content of this manuscript. Dr. JM Tolosana has received honoraria as a lecturer and consultant for Abbott, Boston Scientific and Medtronic. Dr. L. Mont has received unrestricted research grants, fellowship program support, and hononaria as a lecturer and consultant from Abbott, Biotronik, Boston Scientific, Livanova, and Medtronic.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Chugh SS, Havmoeller R, Narayanan K, Singh D, Rienstra M, Benjamin EJ, et al. Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study. Circulation. 2014;129(8):837–47. Scholar
  2. 2.
    Colilla S, Crow A, Petkun W, Singer DE, Simon T, Liu X. Estimates of current and future incidence and prevalence of atrial fibrillation in the U.S. adult population. Am J Cardiol. 2013;112(8):1142–7. Scholar
  3. 3.
    Krijthe BP, Kunst A, Benjamin EJ, Lip GY, Franco OH, Hofman A, et al. Projections on the number of individuals with atrial fibrillation in the European Union, from 2000 to 2060. Eur Heart J. 2013;34(35):2746–51. Scholar
  4. 4.
    Benjamin EJ, Wolf PA, D’Agostino RB, Silershatz H, Kannel WB, Levy D. Impact of atrial fibrillation on the risk of death: the Framingham Heart Study. Circulation. 1998;98:946–52.CrossRefGoogle Scholar
  5. 5.
    Pistoia F, Sacco S, Tiseo C, Degan D, Ornello R, Carolei A. The epidemiology of atrial fibrillation and stroke. Cardiol Clin. 2016;34(2):255–68. Scholar
  6. 6.
    Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace. 2016;18(11):1609–78. Scholar
  7. 7.
    Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, et al. 2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 Guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in partnership with the European Society of Cardiology and in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. J Am Coll Cardiol. 2011;57(11):e101–98. Scholar
  8. 8.
    Gillis AM, Morck M. Atrial fibrillation after DDDR pacemaker implantation. J Cardiovasc Electrophysiol. 2002;13(6):542–7. Scholar
  9. 9.
    Skanes AC, Krahn AD, Yee R, Klein GJ, Connolly SJ, Kerr CR, et al. Progression to chronic atrial fibrillation after pacing: the Canadian Trial of Physiologic Pacing. CTOPP Investigators. J Am Coll Cardiol. 2001;38(1):167–72. Scholar
  10. 10.
    Chutani SK, Shah AN, Kantharia BK. Pacing to prevent atrial fibrillation. Curr Opin Cardiol. 2017;32(1):22–6. Scholar
  11. 11.
    Israel CW, Grönefeld G, Ehrlich JR, Li YG, Hohnloser SH. Long-term risk of recurrent atrial fibrillation as documented by an implantable monitoring device: implications for optimal patient care. J Am Coll Cardiol. 2004;43(1):47–52. Scholar
  12. 12.
    Healey JS, Connolly SJ, Gold MR, Israel CW, Van Gelder IC, Capucci A, et al. Subclinical atrial fibrillation and the risk of stroke. N Engl J Med. 2012;366(2):120–9. Scholar
  13. 13.
    Healey JS, Toff WD, Lamas GA, Andersen HR, Thorpe KE, Ellenbogen KA, et al. Cardiovascular outcomes with atrial-based pacing compared with ventricular pacing: meta-analysis of randomized trials, using individual patient data. Circulation. 2006;114(1):11–7. Scholar
  14. 14.
    Andersen HR, Nielsen JC, Thomsen PE, Thuesen L, Mortensen PT, Vesterlund T, et al. Long-term follow-up of patients from a randomised trial of atrial versus ventricular pacing for sick-sinus syndrome. Lancet. 1997;350:1210–6. Scholar
  15. 15.
    Connolly SJ, Kerr CR, Gent M, Roberts RS, Yusuf S, Gillis AM, 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(19):1385–91. Scholar
  16. 16.
    Lamas GA, Lee KL, Sweeney MO, Silverman R, Leon A, Yee R, et al. Ventricular pacing or dual-chamber pacing for sinus node dysfunction. N Engl J Med. 2002;346:1854–62. Scholar
  17. 17.
    Lamas GA, Orav EJ, Stambler BS, Ellenbogen KA, Sgarbossa EB, Huang SK, et al. Quality of life and clinical outcomes in elderly patients treated with ventricular pacing as compared with dual-chamber pacing. Pacemaker Selection in the Elderly Investigators. N Engl J Med. 1998;338(16):1097–104. Scholar
  18. 18.
    Nielsen JC, Thomsen PE, Højberg S, Møller M, Vesterlund T, Dalsgaard D, et al. A comparison of single-lead atrial pacing with dual-chamber pacing in sick sinus syndrome. Eur Heart J. 2011;32(6):686–96. Scholar
  19. 19.
    Gillis AM, Russo AM, Ellenbogen KA, Swerdlow CD, Olshansky B, Al-Khatib SM, et al. HRS/ACCF expert consensus statement on pacemaker device and mode selection. J Am Coll Cardiol. 2012;60:682–703. Scholar
  20. 20.
    Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, et al. 2018 ACC/AHA/HRS Guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm. 2018.
  21. 21.
    Brandt NH, Kirkfeldt RE, Nielsen JC, Mortensen LS, Jensen GVH, Johansen JB, et al. Single lead atrial vs. dual chamber pacing in sick sinus syndrome: extended register-based follow-up in the DANPACE trial. Europace. 2017;19(12):1981–7. Scholar
  22. 22.
    Sweeney MO, Bank AJ, Nsah E, Koullick M, Zeng QC, Hettrick D, et al. Minimizing ventricular pacing to reduce atrial fibrillation in sinus-node disease. N Engl J Med. 2007;357(10):1000–8. Scholar
  23. 23.
    Vincenti A, Brambilla R, Fumagalli MG, Merola R, Pedretti S. Onset mechanism of paroxysmal atrial fibrillation detected by ambulatory Holter monitoring. Europace. 2006;8(3):204–10. Scholar
  24. 24.
    Guyomar Y, Thomas O, Marquié C, Jarwe M, Klug D, Kacet S, et al. Mechanisms of onset of atrial fibrillation: a multicenter, prospective, pacemaker-based study. Pacing Clin Electrophysiol. 2003;26(6):1336–41. Scholar
  25. 25.
    Coumel P, Attuel P, Lavallée J, Flammang D, Leclercq JF, Slama R. The atrial arrhythmia syndrome of vagal origin. Arch Mal Coeur Vaiss. 1978;71(6):645–56.PubMedGoogle Scholar
  26. 26.
    Mont L, Sambola A, Brugada J, Vacca M, Marrugat J, Elosua R, et al. Long-lasting sport practice and lone atrial fibrillation. Eur Heart J. 2002;23(6):477–82. Scholar
  27. 27.
    Mitchell AR, Sulke N. How do atrial pacing algorithms prevent atrial arrhythmias? Europace. 2004;6(4):351–62. Scholar
  28. 28.
    Nakai T, Watanabe I, Hirayama A. Current status of atrial pacing algorithms for the prevention of atrial fibrillation: should algorithms be used? J Arrhythmia. 2014;30:77–81. Scholar
  29. 29.
    Carlson MD, Ip J, Messenger J, Beau S, Kalbfleisch S, Gervais P, 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(4):627–33. Scholar
  30. 30.
    Padeletti L, Pürerfellner H, Adler SW, Waller TJ, Harvey M, Horvitz L, et al. Combined efficacy of atrial septal lead placement and atrial pacing algorithms for prevention of paroxysmal atrial tachyarrhythmia. J Cardiovasc Electrophysiol. 2003;14(11):1189–95. Scholar
  31. 31.
    Camm AJ, Sulke N, Edvardsson N, Ritter P, Albers BA, Ruiter JH, et al. Conventional and dedicated atrial overdrive pacing for the prevention of paroxysmal atrial fibrillation: the AFTherapy study. Europace. 2007;9(12):1110–8. Scholar
  32. 32.
    •• Munawar DA, Mahajan R, Agbaedeng TA, Thiyagarajah A, Twomey DJ, Khokar K, et al. Implication of ventricular pacing burden and atrial pacing therapies on the progression of atrial fibrillation: a systematic review and meta-analysis of randomized controlled trials. Heart Rhythm. 2019. This is an important reference because it summarizes the current clinical evidence on the topic. It is a systematic review and meta-analysis of the available randomized controlled trials.CrossRefGoogle Scholar
  33. 33.
    •• Boriani G, Tukkie R, Manolis AS, Mont L, Pürerfellner H, Santini M, 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(35):2352–62. This randomized trial showed that pacemakers with atrial preventive pacing + atrial antitachycardia pacing + managed ventricular pacing proved superior to standard dual-chamber pacing in patients with pacing indication and atrial tachyarrhythmias.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    • Padeletti L, Pürerfellner H, Mont L, Tukkie R, Manolis AS, Ricci R, et al. New-generation atrial antitachycardia pacing (reactive ATP) is associated with reduced risk of persistent or permanent atrial fibrillation in patients with bradycardia: results from the MINERVA randomized multicenter international trial. Heart Rhythm. 2015;12(8):1717–25. This article reported the results of a prespecified secondary analysis of the Minerva study, showing the benefits of the new-generation atrial antitachycardia pacing (Reactive ATP).CrossRefPubMedGoogle Scholar
  35. 35.
    • Crossley GH, Padeletti L, Zweibel S, Hudnall JH, Zhang Y, Boriani G. Reactive atrial-based antitachycardia pacing therapy reduces atrial tachyarrhythmias. Pacing Clin Electrophysiol. 2019. This important retrospective study in real-world patients analyzed the benefits of new-generation atrial antitachycardia pacing.CrossRefGoogle Scholar
  36. 36.
    Knight BP, Gersh BJ, Carlson MD, Friedman PA, McNamara RL, Strickberger SA, et al. Role of permanent pacing to prevent atrial fibrillation: science advisory from the American Heart Association Council on Clinical Cardiology (Subcommittee on Electrocardiography and Arrhythmias) and the Quality of Care and Outcomes Research Interdisciplinary Working Group, in collaboration with the Heart Rhythm Society. Circulation. 2005;111(2):240–3. Scholar
  37. 37.
    Israel CW, Hügl B, Unterberg C, Lawo T, Kennis I, Hettrick D, et al. Pace-termination and pacing for prevention of atrial tachyarrhythmias: results from a multicenter study with an implantable device for atrial therapy. J Cardiovasc Electrophysiol. 2001;12(10):1121–8. Scholar
  38. 38.
    Fidalgo ML, Gonzalez JM, Martín J, García R. Algoritmos de prevención y tratamiento de la fibrilación auricular. Cuadernos de estimulación cardiaca. Sociedad Española de Cardiología Medtronic. 2008;1:2.Google Scholar
  39. 39.
    Lee MA, Weachter R, Pollak S, Kremers MS, Naik AM, Silverman R, et al. The effect of atrial pacing therapies on atrial tachyarrhythmia burden and frequency: results of a randomized trial in patients with bradycardia and atrial tachyarrhythmias. J Am Coll Cardiol. 2003;41(11):1926–32. Scholar
  40. 40.
    Boriani G, Padeletti L, Santini M, Gulizia M, Capucci A, Botto G, et al. Predictors of atrial antitachycardia pacing efficacy in patients affected by brady-tachy form of sick sinus syndrome and implanted with a DDDRP device. J Cardiovasc Electrophysiol. 2005;16(7):714–23. Scholar
  41. 41.
    Mont L, Ruiz-Granell R, Martínez JG, Carmona JR, Fidalgo M, Cobo E, 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(1):28–34. CrossRefPubMedGoogle Scholar
  42. 42.
    Brignole M, Auricchio A, Baron-Esquivias G, Bordachar P, Boriani G, Breithardt OA, et al. 2013 ESC guidelines on cardiac pacing and cardiac resynchronization therapy: the task force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Europace. 2013;15:1070–118. Scholar
  43. 43.
    Tracy CM, Epstein AE, Darbar D, Dimarco JP, Dunbar SB, Estes NA 3rd, 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. J Am Coll Cardiol. 2012;60:1297–313. Scholar
  44. 44.
    Sweeney MO, Hellkamp AS, Ellenbogen KA, Greenspon AJ, Freedman RA, Lee KL, 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(23):2932–7. Scholar
  45. 45.
    Jankelson L, Bordachar P, Strik M, Ploux S, Chinitz L. Reducing right ventricular pacing burden: algorithms, benefits, and risks. Europace. 2019;21(4):539–47. Scholar
  46. 46.
    Boriani G, Tukkie R, Biffi M, Mont L, Ricci R, Pürerfellner H, et al. Atrial antitachycardia pacing and atrial remodeling: a substudy of the international, randomized MINERVA trial. Heart Rhythm. 2017;14(10):1476–84. Scholar
  47. 47.
    • Boriani G, Pieragnoli P, Botto GL, Puererfellner H, Mont L, Ziacchi M, et al. Effect of PR interval and pacing mode on persistent atrial fibrillation incidence in dual chamber pacemaker patients: a sub-study of the international randomized MINERVA trial. Europace. 2019;21(4):636–44. This was an important substudy of the randomized MINERVA trial. It showed that PR interval may be used as a selection criterion to identify the optimal pacing mode.CrossRefPubMedGoogle Scholar
  48. 48.
    Ricci RP, Botto GL, Bénézet JM, Nielsen JC, De Roy L, Piot O, et al. Association between ventricular pacing and persistent atrial fibrillation in patients indicated to elective pacemaker replacement: results of the Prefer for Elective Replacement MVP (PreFER MVP) randomized study. Heart Rhythm. 2015;12:2239–46. CrossRefPubMedGoogle Scholar
  49. 49.
    Gasparini M, Steinberg JS, Arshad A, Regoli F, Galimberti P, Rosier A, et al. Resumption of sinus rhythm in patients with heart failure and permanent atrial fibrillation undergoing cardiac resynchronization therapy: a longitudinal observational study. Eur Heart J. 2010;31(8):976–83. Scholar
  50. 50.
    Badhwar N, Chen T, Lee B, Lee R. Spontaneous conversion of atrial fibrillation to sinus rhythm after cardiac resynchronization therapy: case series and review of the literature. Abstract presented Heart Rhythm Scientific Sessions 2019. San Francisco. [Board No S-PO05-238].Google Scholar
  51. 51.
    Birnie D, Hudnall H, Lemke B, Aonuma K, Lee KL, Gasparini M, et al. Continuous optimization of cardiac resynchronization therapy reduces atrial fibrillation in heart failure patients: results of the Adaptive Cardiac Resynchronization Therapy Trial. Heart Rhythm. 2017;14(12):1820–5. Scholar
  52. 52.
    Hsu JC, Birnie D, Stadler RW, Cerkvenik J, Feld GK, Birgersdotter-Green U. Adaptive cardiac resynchronization therapy is associated with decreased risk of incident atrial fibrillation compared to standard biventricular pacing: a real-world analysis of 37,450 patients followed by remote monitoring. Heart Rhythm. 2019;16:983–9. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Margarida Pujol-López
    • 1
  • Rodolfo San Antonio
    • 1
  • José María Tolosana
    • 1
    • 2
  • Lluís Mont
    • 1
    • 2
    • 3
    Email author
  1. 1.Institut Clínic Cardiovascular (ICCV), Hospital ClínicUniversitat de BarcelonaBarcelonaSpain
  2. 2.Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain
  3. 3.Institut Clínic Cardiovascular (ICCV), Hospital ClínicUniversitat de BarcelonaBarcelonaSpain

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