Dual chamber pacemaker an Coumadin

A new patient came to me recently with a dual chamber pacemaker in 2007 for sick sinus syndrome. Later he was placed on Coumadin for "atrial fibrillation". I thought the dual chamber mechanism would eliminate atrial fib so a person would not have to take Coumadin, as this patient has had difficulty keeping his protime in the appropriate range and has had bleeding complications. When I examined him, he did not have atrial fib but had dual pacemaker pacing. Can a patient go into atrial fib with a dual chamber pacemaker and if not why would this patient need to be on Coumadin? Thanks...family doc.

2 Comments

AF & pacemaker

by golden_snitch - 2012-05-04 01:05:31

Hi!

Not sure, if I'm completely right, but:

Pacemakers can in general not treat any kind of fast arrhythmias. As long as the AV-node is working, the only thing a pacemaker can do in a patient with AF is to provide a stable minimum (ventricular) heart rate. Consequently, only "slow fibbers" will have a benefit from having a pacemaker. When the AF episode starts, a dual-chamber pacemaker will switch from DDD pacing into VVI pacing, ignoring completely what's happening in the atriums. That is simply because atrial fibrillation is way too fast for the pacemaker to keep up with. The atrial pacemaker lead can just watch, if one may say so.

Even with an ablated AV-node - the ablate & pace strategy for AF -, your patient will still need to take Coumadin because whilst the connection between atriums and ventricles is cut, the atrial fibrillation is not gone; it continues. In that case it's only that the irregular impulses coming from the atriums will no longer reach the ventricles. The ventricles will be paced, the atriums keep fibrillating and therefore there is still a risk for embolism.

Regarding the INR level: What about home monitoring? I have been doing that ever since I was put on Warfarin in 2005. It works very well. And in the seminar I had to take to get the home monitor, most of the other patients were between age 60 - 85, and they all managed to learn how to do the test. It's easy.

Best
Inga

PM for A-FIB

by Roys - 2012-05-04 07:05:57

Hi
YES i have a Medtronic PM with EnRhythm pacing system that has overdrive pacing (PMOP) to manage recurrence of AF, which means a pacing rate slightly higher than the intrinsic rate, it works for me. But my EP said it it only had a 30% chance of working.
Cheers Roy

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In fact after the final "tweaks" of my pacemaker programming at the one year check up it is working so well that I forget I have it.