Pacemaker therapy in patients with atrial fibrillation.

Pacing is indicated in patients with AF when clinical symptoms are readily attributable to slow ventricular rate and prolonged ventricular pauses. When choosing a pacemaker for implantation, one should consider the importance of a reasonable chronotropic response to exercise and provide a rate-responsive system (VVIR) for those patients who show chronotropic incompetence. In the case of paroxysmal AF, an AV synchronized system may provide protection against deterioration to chronic AF and heart failure and is preferred over VVI pacing, providing that paroxysms are infrequent. Drug-pacemaker interaction is rare, but it is recommended that class IC antiarrhythmic agents should not be used in pacemaker-dependent patients. Cardioversion should be performed with care in patients with a permanent pacemaker, and certain protective measures must be employed to avoid pacemaker destruction or malfunction. Pacemakers, when used according to strict criteria, constitute an integral part of treatment and may improve the quality of life and facilitate the use of necessary drugs in selected patients with AF.