Copy of FAQs Coping with A-Fib: Pacemaker for Too Slow a Heart?
FAQs Coping with A-Fib: Pacemaker
“Now my doctor says I need a pacemaker, because my heart rate is too slow and because I’m developing pauses.
I’m an athlete with A-Fib and have a naturally slow heart rate. Since I developed A-Fib, I was put on atenolol (a beta blocker) which really slows down my heart rate. What should I do?”
Get a second opinion. It’s crazy to go through the risks and lifestyle disruptions of having a pacemaker implanted just to be able to continue taking atenolol.
Because you are an athlete, your heart rate is naturally slow. But it’s normal for you.
As long as you feel fine and aren’t fainting from lack of blood flow, don’t be talked into getting a pacemaker. A slow or even very slow heart rate usually doesn’t cause any harm. As for heart rates, “normal” is indeed a wide swath.
In the words of Dr. John Mandrola:
“Do not implant pacemakers in patients with nonsymptomatic bradycardia (slow heart rate).The same holds for pauses, though they are certainly of more concern than a slow heart rate. Nonsymptomatic slow heart rate or pauses don’t justify exposing patients to the risks of implanting a pacemaker.”
Do not implant pacemakers in patients with nonsymptomatic bradycardia. This includes the wide spectrum of sinus node dysfunction (SND), asymptomatic pauses in patients with permanent AF, and young patients with medication-induced bradycardia. Humans exhibit tremendous variation of heart rate, and impressively slow heart rates frequently cause patients no harm. As for heart rates, ”normal” is indeed a wide swath. Unlike the more sinister high-degree AV block, SND is not immediately fatal. In 2012, there exist many strategies for the treatment of arrhythmia that do not include exposing patients to the risks of implanting a permanent intravascular device.
Back to FAQs: Coping with Your A-Fib
Last updated: Wednesday, August 26, 2020
2020 AF Symposium Challenging Case: 75-Year-Old, A-Fib Increases, Develops Bradycardia, 12-sec Heart Pause
2020 AF Symposium: AF Management
Challenging Case: 75-Year-Old, A-Fib Increases, Develops Bradycardia, 12-sec Heart Pause
by Steve S. Ryan
One of the most interesting sessions at the AF Symposium is the “Challenging Cases in AF Management: Anticoagulation, Arrhythmic Drugs and Catheter Ablation for AF” where leading doctors discuss very frankly their most difficult cases that year.
While several cases were discussed, here I summarize just one case.


Patient History: 75-Year-Old Female
Case presented by Dr. Eric Prystowsky, St. Vincent Hospital, Indianapolis, IN
Dr. Prystowsky described the case of a 75-year-old female with A-Fib of at least three years duration. Before she came to Dr. Prystowsky, she was on Sotalol 40 mg 2/d and aspirin.
She was doing fine until a few months before when her A-Fib attacks became more frequent and with a more rapid rate. She also developed bradycardia and had a 12-second pause in heart beat.
Pacemaker and Pericardial Effusion: She had a pacemaker installed (but not by Dr. Prystowsky). During the implanting of the pacemaker, she developed a pericardial effusion (bleeding from the heart into the pericardium sac). She was not on anticoagulants.
Two weeks after implanting the pacemaker, she felt lousy with recurring palpitations.
Treatment by Dr. Prystowsky
Flecainide added: Dr. Prystowsky put her on flecainide 100 mg 2/day. She had slightly elevated blood pressure. She was also on aspirin, metoprolol, and Atorvastatin (to lower blood pressure by treating high cholesterol and triglyceride levels).
The patient had repeatedly been offered a catheter ablation, but she declined each time.
Reset Pacemaker: The pacemaker was controlling her atrium 93% of the time. Her Ejection Fraction was 55%-60% (a good range).
Dr. Prystowsky reprogrammed her pacemaker to change her AV interval. He stopped the aspirin, and put her on apixaban (Eliquis) 5 mg 2/d. He ordered a stress echo test to check her heart.
She felt better for 5 days.
Moderate Pericardial Effusion; Medications Adjusted
The patient then developed a moderate (“significant”) pericardial effusion.
Dr. Prystowsky stopped the apixaban (probably the cause of the pericardial effusion). Because she still had some symptomatic episodes of A-Fib (although much better), he then increased the flecainide to 150 mg.
Contributing Role: Referring to the cause of the patient’s pericardial effusion, Dr. Prystowsky faced the fact that “I did it.”
She experienced bad side effects with the increased dosage of flecainide. He put her on 100 mg 3/day to reduce the side effects.
The patient had repeatedly been offered a catheter ablation, but she declined each time.
Minimizing Pacing; Medication Adjusted
The patient’s ventricular pacing produced a wide QRS which Dr. Prystowsky said “worried the hell out of me.” He tried to minimize the pacing she received.
A CT scan revealed that her pacemaker incisions were fine, and that she had no more pericardial effusion. He re-started apixaban. She felt great.
He wound up putting her on amiodarone 200 mg which she tolerated well (previously she didn’t react well to Sotalol).
Dr. Prystowsky’s Lament
He described what he called his “shpilkes” index (Yiddish for anxiousness). When he talks to his fellows, “If you go home and worry about your patient at midnight, you ought to re-think everything.”
One Year Later and Lesson Learned
A year later she came in complaining of palpitations. Her pacemaker revealed that she only had 2 minutes of A-Fib in six months. Dr. Prystowsky told her, “I can’t do better than that.”
Dr. Prystowsky told the attendees that he would never again put a woman of her age on flecainide 150 mg.
He wrote me that it’s been over a year, and the patient is doing great.
If you find any errors on this page, email us. Y Last updated: Monday, February 22, 2021
Return to 2020 AF Symposium Reports
A-Fib Pause: To Pace or Not to Pace…That is the Question
I’ve posted about my A-Fib retuning last Fall and subsequently having a Medtronic Reveal LINQ Insertable Cardiac Monitor (ICM)—one of the world’s smallest cardiac monitors—inserted just under the skin near my heart. Each night my Reveal Linq wireless monitor transmits that day’s data by wireless connection to my EP, Dr. Shephal Doshi.
Surprise—I Didn’t Feel a Thing
One morning in the week following my successful RF catheter ablation, at 6:27 am unbeknownst to me, my Linq recorder captured this episode—a seven-second pause:


The next morning Dr. Doshi was on the phone telling me to come into the office immediately. He showed me the printout, and I was amazed.
In this second graphic, called a scatter plot, you can clearly see the dots representing the pause (outlined by a red box). The differences between consecutive R-wave intervals reveal patterns in the rhythm.


Wow, 7-seconds—that’s a huge pause! It’s no wonder Dr. Doshi and his office called me the next day. He wanted to install a pacemaker right away and scheduled it for a week later. He also told me not to drive a car.
Remember: Your Best Patient Advocate is You
Unlike when I had A-Fib back in 1997, this time I wasn’t feeling any dizziness during the day.
At A-Fib.com, we always encourage you to be your own best patient advocate (which can include your spouse or partner. too.) And to not blindly follow your doctor’s advice. Always educate yourself. So I read up on pacemakers.
What is a Pacemaker?
In this instance, pacemakers are used to treat a slow heartbeat in people with A-Fib. It’s a small device that monitors your heartbeat and sends out a signal to stimulate your heart if it’s beating too slowly. The device is made up of a small box called a generator. It holds a battery and tiny computer.


Very thin wires called leads connect the pacemaker to your heart. Impulses flow through the leads to keep the organ in rhythm. There are also “leadless” pacemakers which are entirely installed inside your heart.
Installing a Pacemaker: The doctor programs and customizes the pacemaker for each patient to help keep their heart in rhythm. The surgery to put in the device is safe, but there are some risks, such as bleeding or bruising in the area where your doctor places the pacemaker, infection, damaged blood vessel or collapsed lung. You may need another surgery to fix it.
Life with a Pacemaker: Sometimes the impulses from a pacemaker cause discomfort. You may be dizzy, or feel a throbbing in your neck.
Once you have one put in, you might have to keep your distance from objects that give off a strong magnetic field, because they could affect the electrical signals from your pacemaker like metal detectors, cell phones and MP3 players and some medical machines, such as an MRI
In general, it is a permanent installation—you’ll have it for the rest of your life.
VIDEO: Traditional and Leadless Pacemakers Explained. Peter Santucci, MD, is a cardiologist with Loyola University Medical Center; he describes the traditional pacemaker and it’s installation using graphic animations.Then compares with the miniaturized leadless version. 2:30 min. Posted by Loyola Medical. Go to video.
Considering a Pacemaker: Pros and Cons
Patti and I discussed the pros and cons of a pacemaker. In this instance, my heart was beating too slowly. But that’s normal for me. Because of years of running and exercise, my resting heart rate is in the high 50s, which is very low compared to others with A-Fib.
The three-month “blanking” period following my ablation is when my heart is healing and learning to once again beat in normal sinus rhythm. That’s why it’s common for A-Fib to recur during this time.


It doesn’t mean your ablation was a failure—think of it like planting a fruit tree. The tree might not produce fruit right way, but give it time to acclimate, absorb the nutrients in the soil, to grow stronger and bask in the sun. So I’m giving my heart some time, too.
Hitting the Pause Button on a Pacemaker for Now
In the meantime, I haven’t had another pause and have remained A-Fib free. I am hoping that this 7-second pause was a one-time thing and that my heart will stay in normal sinus rhythm in the months to come.
Dr. Doshi wants to install a “leadless” pacemaker which would be entirely installed inside my heart. Having that installed is a big step for me, one that I’ll have to live with for the rest of my life.
So, I decided to wait on having it installed. I’ll reconsider a pacemaker after my 3-month blanking period is behind me.
I’ll keep you posted on the status of my A-Fib post-ablation.
VIDEO: Pacemakers—Traditional and Leadless Explained
Dr.Peter Santucci, is a cardiologist with Loyola University Medical Center; He describes the traditional pacemaker and it’s installation using graphic animations. Then compares with the miniaturized leadless version. 2:30 min. Posted by Loyola Medical.
YouTube video playback controls: When watching this video, you have several playback options. The following controls are located in the lower right portion of the frame: Turn on closed captions, Settings (speed/quality), Watch on YouTube website, and Enlarge video to full frame. Click on arrow icon to select.
If you find any errors on this page, email us. Y Last updated: Friday, August 16, 2019
Videos: Arrhythmias Animations by St. Jude Medical
Sorry. These videos are no longer available.
Three short animations on ‘understanding arrhythmias and treatment options’ from St Jude Medical:
- Atrial Flutter: Fast Heartbeat Arrhythmia (fast heartbeat arrhythmia) (:28 sec.)
- Pacemaker Treatment Option (too slow heart beat) (:49 sec.)
- Implantable Cardioverter Defibrillator (ICD) (dangerously too fast heart beat) (:57 sec.)
If you find any errors on this page, email us. Y Last updated: Thursday, April 9, 2020
With 3-4 Second Pauses, Do I Need a Pacemaker?
We’ve answered a new FAQ about understanding A-Fib with long pauses and if a pacemaker is appropriate.
“I have paroxysmal A-Fib with “pauses” at the end of an event. I can’t tell how many of these I have experienced. Will they stop if my A-Fib is cured?
My cardiologist recommends a pacemaker to prevent blackouts during a pause as well as other serious heart problems. I am willing, but want to learn more about these pauses first.”
I had the same problem. I’d get pauses as long as 6 seconds and get dizzy, I felt like I was about to faint, etc. It was very frightening. But the pauses completely disappeared when my A-Fib was cured by a catheter ablation back in 1998.
Pauses are “Normal” in A-Fib
Pauses of up to 4 seconds duration in atrial fibrillation are considered as ‘normal’. Just because you have pauses doesn’t mean there is something wrong with your Sinus or AV Node and doesn’t mean that you need a pacemaker. When you are returned to normal sinus rhythm (NSR), these pauses usually disappear.
Unfortunately, many cardiologists don’t know this and will try to rush you into having a pacemaker implant…Read the rest of my answer… .
FAQs Understanding A-Fib: With A-Fib Pauses—Do I Need a Pacemaker?
FAQs Understanding A-Fib: Pacemaker for Pauses?
I have paroxysmal A-Fib with “pauses” at the end of an event. I can’t tell how many of these I have experienced. Will they stop if my A-Fib is cured?
I am willing, but want to learn more about these pauses first.”
I had the same problem. I’d get pauses as long as 6 seconds and get dizzy, I felt like I was about to faint, etc. It was very frightening. But the pauses completely disappeared when my A-Fib was cured by a catheter ablation back in 1998.
Pauses are “Normal” in A-Fib
Pauses of up to 4 seconds duration in atrial fibrillation are considered as ‘normal’. Just because you have pauses doesn’t mean there is something wrong with your Sinus or AV Node and doesn’t mean that you need a pacemaker. When you are returned to normal sinus rhythm (NSR), these pauses usually disappear.
Unfortunately, many cardiologists don’t know this and will try to rush you into having a pacemaker implant.
Monitoring Your Symptoms
Are you symptomatic? Do you fall or faint from these pauses? (This is different from occasionally feeling lightheaded or dizzy.)
If your cardiologist hasn’t yet suggested it, you may need to wear a holter or similar monitor for a few days (or up to a month or longer).
Monitoring will tell your doctor exactly how long your pauses are and how often you have them.
Avoid Getting a Pacemaker, if You Can
I can understand your cardiologist’s concern, but try to avoid getting a pacemaker, if you can.
If you do have to get a pacemaker, make sure the cardiologist guarantees that it can and will be easily removed once you are restored to normal sinus rhythm (NSR). You don’t want to be saddled with a pacemaker for life when you don’t need it.
Depending on how a pacemaker is installed, it may make a catheter ablation more difficult. You may have to go to a more experienced EP for your ablation.
Be assertive. You may have to be very assertive about this. Most cardiologists will insist that you keep the pacemaker forever. (But it isn’t so.)
Cure Your A-Fib=No More Pauses
Ask your doctor about antiarrhythmic drugs. They generally don’t “cure” A-Fib but may reduce your pauses.
If your pauses cause you problems, consider a catheter ablation to cure your A-Fib.
Once you no longer have A-Fib, those pauses should stop and your heart should beat again in normal sinus rhythm.
To read a first-hand story about pacemakers, see Personal A-Fib Story #50: Pacemaker & A-Fib Ablation—You Can Have an A-Fib Ablation if You Have a Pacemaker
Go back to FAQ Understanding A-Fib
FAQs Coping with A-Fib: Pacemaker for Too Slow a Heart?
FAQs Coping with A-Fib: Pacemaker
I’m an athlete with A-Fib and have a naturally slow heart rate. Since I developed A-Fib, I was put on atenolol (a beta blocker) which really slows down my heart rate. What should I do?”
Get a second opinion. It’s crazy to go through the risks and lifestyle disruptions of having a pacemaker implanted just to be able to continue taking atenolol.
Because you are an athlete, your heart rate is naturally slow. But it’s normal for you.
As long as you feel fine and aren’t fainting from lack of blood flow, don’t be talked into getting a pacemaker. A slow or even very slow heart rate usually doesn’t cause any harm. As for heart rates, “normal” is indeed a wide swath.
In the words of Dr. John Mandrola:
“Do not implant pacemakers in patients with nonsymptomatic bradycardia (slow heart rate).The same holds for pauses, though they are certainly of more concern than a slow heart rate. Nonsymptomatic slow heart rate or pauses don’t justify exposing patients to the risks of implanting a pacemaker.”
Back to FAQs: Coping with Your A-Fib
Last updated: Tuesday, August 20, 2019
Pacemakers & ICDs
Pacemakers & Implantable Cardioverter Defibrillator (ICD)
Pacemakers


A pacemaker is a small device that sends electrical impulses to the heart muscle to maintain a regular heart rate. In general, pacemakers are not very effective for preventing A-Fib and are not specifically used to treat A-Fib. A pacemaker does not cure A-Fib. But they can be of benefit to some patients. Newer dual chamber pacemakers can possibly terminate A-Fib episodes with pacing and supress Premature Atrial Contractions (PACs) from triggering A-Fib by overdrive pacing.
Implanting a pacemaker seems to be most helpful if you have a slow heart rate or pauses (5+ seconds) as a result of taking A-Fib medications. But there is a danger for patients with this approach. A slow or even very slow heart rate usually doesn’t cause any harm. As for heart rates, “normal” is indeed a wide swath. Some people, particularly athletes, can have a very slow heart rate and be perfectly healthy. The same holds for asymptomatic pauses.
In the words of Dr. John Mandrola:
“Do not implant pacemakers in patients with non-symptomatic bradycardia (slow heart rate).1
Non-symptomatic slow heart rate or pauses don’t justify exposing patients to the risks of implanting a pacemaker. Another consideration is that implanting pacemaker leads in the veins of the upper chest often prevents or hinders future procedures that require vascular access like a Pulmonary Vein Ablation/Isolation (PVI/A).
A pacemaker usually isn’t implanted unless your heart rate is too slow2 or you have Sinus Node and/or Atrioventricular (AV) Node problems. But be advised that pacemakers tend to have bad effects over the long term, “…a long-term morbidity (is) associated with a pacemaker.”3 Leadless pacemakers seem to have less complications than traditional ones.
For more information on Pacemakers, you may want to visit the pacemaker chat site: pacemakerclub.com. (Thanks to Mara for alerting us to this site.)
[I admit to not knowing much about pacemakers. Happily one of the A-Fib.com’s contributors installs pacemakers and offers the following observations.
“I like to tell patients who receive pacemakers that, after a couple of months, they can have a VERY active, normal lifestyle. All of the current pacers have a “rate responsive” mode, meaning they are designed specifically for activity. The more active you are, the faster the pacer goes. Three triathlon runners, and two NFL players have pacers. Most people forget they have a pacemaker.
A recent trend is to implant the ventricular lead on the septum vs. the right ventricular apex, which gives better cardiac output and a more ‘normal’ heartbeat. You might want to ask your doctor about this possibility. Even if your doctor does not prefer this technique, he/she will be impressed that you did your homework.
In addition, you always want a dual chamber pacer which will give better cardiac output. It will also attempt to synchronize between the atria and ventricles, unless the patient is in Chronic A-Fib. If the A-Fib is intermittent, the pacer will temporarily switch modes to VVIR (ventricular only pacing) during the A-Fib, and then back to normal DDDR (dual chamber) pacing when the A-Fib terminates. This is all done by the device memory/logic program.
So, during A-Fib, the DDDR pacer will switch to VVIR and pace only the ventricle during the A-Fib.”
Key to the acronyms.4
Implantable Cardioverter Defibrillator (ICD)


An implantable cardiac defibrillator (ICD) is a device that is put within the body and is designed to recognize certain types of abnormal heart rhythms (arrhythmias) and correct them by delivering precisely calibrated and timed electrical shocks, when needed, to restore a normal heartbeat.
Having a defibrillator implanted in your heart is, from the point of view of most A-Fib patients, not a probable option. A defibrillator shock is painful, like being “kicked in the chest.” Most people would rather have A-Fib than risk being shocked throughout the day and night. Also, it does not address the underlying problem or condition of your heart that causes your A-Fib.
Fewer than 10% of patients get shocked when a shock isn’t needed, according to Edward K. Kasper, MD of The Johns Hopkins Hospital..5 In another study 18% of patients with A-Fib received inappropriate first shocks.6
More than 30% of people who have ICDs develop emotional problems such as anxiety and depression—in part due to worry and uncertainty over whether the device will deliver an unnecessary shock and the fear of being shocked.7
What’s it like living with an ICD and A-Fib? Roby T. shared:
“The worst part was the ICD firing,” he recalls. “It hit me like a baseball bat and knocked me over.” His wife, Mary, was afraid to leave him alone. And the anxiety levels took their toll, even during sleep. “He became really anxious expecting a firing at any time,” she says. “You could see the fear in his eyes,” she reluctantly remembers. “He had to start taking antidepressants.”8
Our A-Fib.com pacemaker expert writes:
“Defibrillators are far more complicated (than pacemakers). When people report getting a big shock (500-700 volts) from the unit, that was probably for V (ventricular) Fib, not A-Fib, if the unit is programmed properly.
One good thing about the V-Fib is that it is usually (not always) proceeded by Ventricular Tachycardia, a much slower, organized rhythm that often responds to painless anti-tachycardia pacing. We will attempt anti-tachycardia overdrive pacing for several different patterns before we finally give up and go to the full output shock.”
Last updated: Friday, December 25, 2020
Return to Treatments for Atrial Fibrillation
- Mandrola, John “Choosing wisely: The electrophysiology list of five don’ts http://www.medscape.com/viewarticle/802018↵
- “Atrial Fibrillation Educational Material” University of Pennsylvania. 2002, p. 3.↵
- Prystowsky, “Should atrial fibrillation ablation be considered first-line therapy for some patients?” Circulation 2005;112:1214-1231, p. 1228.↵
- Key to the acronyms used in the Pacemaker quote:
“DDD” signifies a dual chamber pacer, capable of sensing and pacing in both the atrium and the ventricle
“VVI” is ventricle only
“AAI” is atrium only
“R” signifies Rate Response, a programmable on/off feature which increases the pacing during activity↵ - Kasper, Edward K., MD. The Johns Hopkins Hospital,”How to Save Your Life If You Have Heart Failure.” Bottom Line Health, May, 2012, p. 9.↵
- Cesario, D. et al. The Role of Atrial Fibrillation in CRT-D Patients: The ATTITUDE Study Group. The Journal of Innovations in Cardiac Rhythm Management. 6 (2015), 1873-1880.↵
- Kasper, Edward K., MD. The Johns Hopkins Hospital,”How to Save Your Life If You Have Heart Failure.” Bottom Line Health, May, 2012, p. 9↵
- Roby’s Arrhythmia Story. Published on MyFastHeartBeat.com Last accessed November 5, 2012.↵