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Why would someone with AFib need a pacemaker?

Atrial fibrillation (AFib) is a heart condition that causes an irregular and often abnormally fast heart rate. Some people with AFib may need a pacemaker to help regulate their heart rhythm and rate. A pacemaker is a small device that’s placed in the chest or abdomen to help control abnormal heart rhythms. There are several reasons why a pacemaker may be recommended for someone with AFib.

AFib Can Lead to Bradycardia

One of the main reasons someone with AFib may need a pacemaker is if they develop a slow heart rate called bradycardia. Bradycardia occurs when the heart rate drops below 60 beats per minute. People with AFib are at increased risk for developing bradycardia for a few reasons:

  • The abnormal electrical signals caused by AFib can disrupt the heart’s natural pacemaker cells, leading to a slower than normal heart rate.
  • Some of the medications used to treat AFib, like beta blockers or calcium channel blockers, can cause the heart rate to slow down.
  • Structural problems with the heart’s electrical system resulting from long-standing AFib can also lead to bradycardia.

If bradycardia becomes severe, it can cause bothersome symptoms like fatigue, dizziness, and fainting. A pacemaker can be implanted to stimulate the heart to beat at an appropriate rate and help relieve symptoms.

AFib Patients May Develop Heart Block

Another reason for needing a pacemaker with AFib is if the abnormal heart rhythms lead to a condition called heart block. Heart block occurs when the electrical signals that control the heartbeat are disrupted as they move through the heart.

There are different types of heart block:

  • First-degree heart block – Delayed electrical conduction
  • Second-degree heart block – Intermittent disrupted signals
  • Third-degree heart block – No electrical signals get through

The abnormal electrical signals caused by AFib can sometimes lead to higher degrees of heart block. A pacemaker can help override the blocked electrical signals by pacing the heart to contract and maintain an adequate heart rate.

To Regulate Heart Rate After Ablation

Some patients with AFib undergo a procedure called catheter ablation to destroy small areas of heart tissue causing the abnormal rhythms. Catheter ablation can help many people with AFib, but it also carries a risk of complications like heart block or bradycardia requiring a pacemaker.

Doctors may recommend implanting a pacemaker at the same time as the ablation procedure as a precaution. This allows the pacemaker to stabilize the heart rate if conduction disruptions occur. Pacemakers can be lifesaving in these situations.

Pacemakers Improve Symptoms of AFib

Even if significant bradycardia or heart block are not present, some patients report feeling better with a pacemaker. Pacemakers can help regulate the ventricular rate during AFib episodes. Keeping the heart rate from getting too fast improves AFib symptoms like palpitations, shortness of breath, and reduced exercise tolerance.

Patients also often describe just feeling better overall once the pacemaker regulates their heart rhythm. Since quality of life is an important consideration when managing AFib, pacemakers are sometimes placed to provide symptom relief.

Pacemakers Allow AFib Medications to Be Used Safely

Medications that control heart rate like beta blockers and calcium channel blockers are commonly used in AFib patients. As mentioned earlier, a potential side effect of these medications is bradycardia or heart block.

Having a pacemaker in place allows these AFib drugs to be prescribed more safely. The pacemaker acts as a safety net, preventing the heart rate from dropping too low in response to the medications.

Who Needs a Pacemaker for AFib?

Not everyone with AFib needs a pacemaker. Here are some factors doctors consider when determining if someone should get a pacemaker for AFib:

  • Presence of significant bradycardia or heart block
  • How well symptoms are controlled with medications
  • If long pauses are seen on EKG monitoring
  • Presence of early heart failure
  • If the patient has reduced exercise tolerance
  • If AFib ablation or other heart surgery is planned
  • Personal preference and quality of life considerations

In general, pacemakers are more likely to be recommended in AFib patients who are older, have structural heart disease, or have symptoms that persist despite medications.

Types of Pacemakers Used for AFib

There are a few different types of pacemakers that may be used in patients with AFib:

  • Single chamber pacemaker – Paces one chamber of the heart, usually the right ventricle.
  • Dual chamber pacemaker – Paces two chambers, the right atrium and right ventricle.
  • Biventricular pacemaker – Paces both ventricles for patients with heart failure.

Dual chamber pacemakers are most commonly chosen for AFib as they can pace the atria and ventricles as needed. The cardiologist will determine the most appropriate pacemaker based on each patient’s specific needs.

The Pacemaker Implantation Procedure

The pacemaker implantation procedure is minimally invasive, often taking 1-2 hours. It may be done under local anesthesia or light sedation. The basic steps include:

  1. Access the vein under the collarbone and insert the pacemaker leads into the heart under X-ray guidance.
  2. Test the lead placement and pacemaker function.
  3. Create a small pocket below the collarbone for the pacemaker generator.
  4. Connect the leads to the generator and place it into the pocket.
  5. Program the pacemaker settings and test that it is working properly.
  6. Close the incisions.

Patients usually stay in the hospital overnight and are discharged home the following day. Having a pacemaker implanted is generally very safe with few complications. Recovery involves taking it easy for a week or two to allow complete healing.

Living with a Pacemaker for AFib

Once the pacemaker is implanted, regular follow-up is needed to monitor the device and make any necessary programming changes. The cardiologist will want to see patients in clinic every 6 to 12 months. The pacemaker battery generally lasts somewhere between 5-15 years before needing replacement.

People with AFib pacemakers will be able to resume their normal activities for the most part. Precautions need to be taken around strong electrical or magnetic fields that could potentially interfere with the pacemaker function. Patients receive an ID card containing information about their device that should be shown to security personnel at airports.

By regulating heart rhythm, pacemakers can significantly improve quality of life in people with difficult to control AFib. The risks and recovery time associated with pacemaker surgery are generally low while the benefits are substantial. Patients with concerning symptoms related to AFib should speak with a cardiologist about whether a pacemaker could be helpful for them.


Atrial fibrillation is a complex heart rhythm disorder. Some patients with AFib go on to develop problematic slow heart rhythms like bradycardia or heart block that can cause intolerable symptoms. Others have AFib that causes symptoms that are hard to control even with medications.

Implanting a permanent pacemaker is an effective treatment option for many people with symptomatic AFib. The pacemaker provides regular electrical stimuli to the heart to maintain an appropriate rhythm and rate. This prevents pauses and dramatically improves AFib symptoms.

Pacemakers allow medications to work better and improve quality of life in AFib patients. The implantation procedure is low risk when performed by an experienced cardiologist. For selected patients, pacemakers can be life-changing devices. Anyone with difficult to manage AFib should discuss the potential benefits of a pacemaker with their doctor.