Pacemaker clinics and anticoagulation for atrial fibrillation

We welcome the study by Cabrera et al.¹ in the November issue of the journal which is a timely reminder of poor anticoagulation in patients with a permanent pacemaker and atrial fibrillation (AF). Their conclusions are similar to our data collected in Norfolk and Norwich University Hospital, UK over 2 months in 2011. In our region, the pacing checks take place in the hospital by independent cardiac physiology technicians, even when patients are only followed in the community by their family physicians. We reviewed the case notes and/or electronic records of 337 patients seen in the hospital pacing clinic at high risk of thromboembolism (with a CHA₂DS₂-Vasc≥ 2) and an atrial arrhythmia suitable for anticoagulation consideration (for this we considered permanent/persistent AF/flutter and paroxysmal AF/flutter >30 min as suitable). 113/337 (33.5%) had AF/flutter suitable for anticoagulation (men= 51, median age 83, mean CHA₂DS₂-Vasc= 3.7, permanent AF/flutter=83).

In 26 of 113 (23.0%) AF/flutter only developed after the pacemaker insertion and the family physician had not been informed therefore anticoagulation was not considered. In another 20 of 113 cases (17.7%), the family physicians had been informed of the AF/flutter yet these patients remained on antiplatelets alone. Fifty of 113 patients took warfarin (44.3%) and 17 of 113 patients (15.0%) declined or could not tolerate warfarin.

In patients with a permanent pacemaker, the paced rhythm can obscure the electrocardiographic identification of atrial arrhythmias in the community. Therefore, assessment for anticoagulation might not occur. Both the data from Cabrera et al.¹ study and our data suggest that communication between pacemaker clinics and family physicians remains crucial for appropriate consideration of anticoagulation. Pacemaker clinics offer a unique opportunity to report newly identified AF/flutter and act as a prompt/reminder for family physicians to consider warfarin in accordance with the new ESC guidance² in patients with existing AF/flutter. However, this can only be achieved if there is excellent communication between pacing clinics and family physicians.

Conflict of interest: none declared.