01 Indications for Cardiac Pacing

ACC/AHA Guidelines for

Pacemaker and ICD Implant
Class of Recommendation (COR)
Class I: conditions for which there is good evidence
and/or general agreement that the therapy is
appropriate
Class II: conflicting evidence or divergence of
opinion
II a: favor of usefulness/efficacy
II b: less well established

ACC/AHA Guidelines for

Pacemaker and ICD Implant
Class III: evidence and / or general agreement that
the therapy is not useful or effective
COR III : No benefit
Procedure/test not helpful
Treatment with no proven benefit
COR III: Harm
Procedure/ test of excess cost w/o benefit or
harmful
Treatment harmful to patients
Gregoratos, Circ 1998; 97: 1325-1335
Epstein Circ 2013;127:e283-e352
(2012 Focused Update)

ACC/AHA Guidelines for

Pacemaker and ICD Implant
Level of Evidence
A : data derived from multicenter randomized trials
or meta-analyses
B : data from single randomized trial or nonrandomized studies or observational studies
C : expert consensus, case studies or standard of
care but no formal studies
Gregoratos, Circ 1998; 97: 1325-1335

Indications for Pacing

Symptomatology
+ Documented
Events =
Reliable Indications
for Pacing

ECG documentation in the medical

record is essential !
5

Symptomatic Bradycardia
Defined as a documented bradyarrhythmia that is
directly responsible for development of:
Definite correlation of symptoms is required
clinical manifestations of syncope or near syncope
Transient dizziness or lightheadedness
Confusional states resulting from cerebral
hypoperfusion
Fatigue, exercise intolerance and congestive heart
failure
* Not to be confused with physiological sinus
bradycardia ( as occurs in highly trained athletes)

Bradycardias
Causes:
1.

Myocardial ischaemia / infarction

2.

Drugs e.g. digitalis, beta blockers

3.

Aortic stenosis

4.

Acute rheumatic fever, myocarditis

5.

Hypothyroidism

6.

Physiological

7.

Neuromuscular disease (e.g. myotonic muscular

dystrophy, Erb, etc)
7

Sinus Node Dysfunction

(Sick Sinus Syndrome)
Sinus Bradycardia
Sinus Arrest
SA Exit Block
Bradycardia-Tachycardia
Syndrome
Symptomatic chronotropic incompetence

Sinus Node Dysfunction

Class I
SND with documented symptomatic bradycardia,
including frequent sinus pauses that produce symptoms
(Level of Evidence:C)
Symptomatic chronotropic incompetence (Level of
evidence: C)
(?Definition: 70% MPHR or MaxHR,100/min)
Symptomatic sinus bradycardia that results from
required drug therapy for medical conditions (Level of
evidence: C)

Sinus Node Dysfunction

Class II a
Reasonable in SND with HR <40bpm when a clear
association between significant symptoms consistent with
bradycardia and the actual presence of bradycardia has
NOT been documented (Level of evidence: C)
Reasonable for syncope of unexplained origin when
clinically significant abnormalities of SN function are
discovered or provoked in EP studies (Level of evidence :
C)

10

Sinus Node Dysfunction

Class IIb
May be considered in minimally symptomatic patients
with chronic HR <40 bpm while awake (Level of
evidence : C)

Sinus Node Dysfunction

Class III
SND inasymptomaticpts (Level of evidence :C)
Symptoms suggestive of bradycardia have been
clearly documented to be unrelated to bradycardia
(Level of evidence: C)
Symptomatic sinus bradycardia due to nonessential
pharmacologic Rx (Level of evidence : C)

12

AV Block

First degree
Second degree
1.
2.
3.

Type I: Wenckebach
Mobitz II
2:1 (Blocking of 2 or more
consecutive P waves with
some conducted beats)
? Unequivocally type I or
type II
Width of QRS
AF: prolonged pause (>5s)
should be considered to be
advanced second degree AV
block

Anatomical:
Supra-His, Intra-His or Infra-His

Third degree
Absence of AV conduction

Chronic stable
Asystolic
13

Heart block

14

AV Block
First Degree AV Block

Significant FIRST degree AV Block (PR >300 ms)

Atrial systole in close proximity to preceding ventricular systole
Hemodynamic consequences associated with retrograde (VA)
conduction signs and symptoms similar to pacemaker syndrome
Atrial contraction occurs before complete atrial filling predispose to
late diastolic regurgitation increase in PCWP and decrease CO
15

AV Block
Mobitz II

No change in PR interval preceding or following blocked P

wave
Often associated with wide QRS (infra-nodal or intraHisian
block)

16

AV Block
2nd Degree - Mobitz II

Mobitz II 2nd AV Block may be associated with abrupt

asystolic complete heart block without a stable escape focus
( ie progression to third degree AV block is common and
sudden)
Type II second degree block with a wide QRS typically
indicates diffuse conduction system disease and constitutes
an indication for pacing even in absence of symptoms
17

AV Block
Class I
Third degree AV block and advanced second degree AV block at
any anatomic level associated with bradycardia with symptoms (
including heart failure) or ventricular arrhythmias presumed due
to AV block (C)
Associated with arrhythmias and other medical conditions that
require drug therapy that results in symptomatic bradycardia ( C)
In awake, symptom free pts in SR, documented peroids of
asystole 3.0 s or any escape rate 40 bpm or an escape rhythm
below the AV node ( C)
after catheter ablation of AV junction (C )
post-operative AV block that is not expected to resolve after
cardiac surgery ( C)
associated with neuro-muscular diseases with AV block, such
as myotonic muscular dystrophy, Kearns-Sayre syndrome, Erb
dystrophy ( limb-girdle muscular dystrophy) and peroneal
muscular atrophy, with or without symptoms (B)
18

AV Block
Class I (continued)
High grade second degree AV block if symptomatic and
not reversible ( B )
Asymptomatic persistent third degree AV block at any
anatomic site with average awake V rate of 40 bpm or
faster if cardiomegaly or LV dysfunction is present or if
the site of block is below AV node (B)
Second and third-degree AV block during exercise in the
absence of myocardial ischemia (C)

AV Block
Class II a
Asymptomatic CHB (without cardiomegaly) of HR > 40 bpm (
C)

Asymptomatic Type I if intra- or infra-His found at EP study (B

)

FIRST or second degree AV block with symptoms similar to

those of pacemaker syndrome or hemodynamic compromise ( B
)

Asymptomatic Type II 2nd Degree AV block with narrow QRS

* when type II 2nd degree with wide QRS (including isolated
RBBB), pacing becomes a Class I recommendation)

Class II b
Considered for neuromuscular diseases with any degree of AV
block (including First degree), with or without symptoms (B)
Unpredictable progression of AV conduction disease
AV block in setting of drug use and/or drug toxicity when block
is expected to recur even after the drug is withdrawn ( C)
20

AV Block
Class III

Not indicated for asymptomatic first degree

AV block ( B)
Not indicated for asymptomatic type I second
degree AV block at supra His level or not
known to be intra- or infra-Hisian (C )
Not indicated AV block that is expected to
resolve and is unlikely to recur ( eg drug
toxicity, Vagal tone , hypoxia in sleep apnoea
syncrome in absence of symptoms) (B)

Chronic Bifascicular Block

The ACC guideline does not use trifascicular
block
Bifascicular Block- Impaired conduction
below the AVN in the R and L bundles
Alternating BBB ( or bilateral BBB) = clear
ECG evidence for block in all 3 fascicles
manifested on successive ECGs
Situations to indicate Bifascicular block:
1.
2.

Alternating R/L BBB

Alternating RBBB/L AH & RBBB/L PH
1st degree HB in association with bifascicular
block and symptomatic advanced AV block have
a high mortality rate and a substantial incidence
of sudden death
22

MARROW
23

WILLIAM

24

ESC Guideline
Definition

Bifascicular Block: RBBB + LAH or LPH

LBBB
Trifascicular Block:1 AVB + Bifascicular
Block
(or sequential ECG showing
block in all fascicles)
Pacing in Asymptomatic pts
Bifascicular or trifascicular block with intermittent 2nd or 3rd
degree AVB or prolonged HV when EPS is done for other
reasons
25

Permanent Pacing in
Chronic Bifascicular Block
In the presence of syncope, consideration for VT/VF

I IIa IIb III

I IIa IIb III

I IIa IIb III

Permanent pacemaker implantation is indicated

for advanced second-degree AV block or
intermittent third-degree AV block.
Permanent pacemaker implantation is indicated
for type II second-degree AV block.

Permanent pacemaker implantation is indicated

for alternating bundle-branch block.
26

Permanent Pacing After the Acute Phase of

Myocardial Infarction*
*Pacing does not affect long term prognosis which is
dependent on the amount of myocardial damage.
I IIa IIb III

Permanent ventricular pacing is indicated for persistent

second-degree AV block in the His-Purkinje system with
alternating bundle-branch block or third-degree AV block
within or below the His-Purkinje system after STsegment elevation MI.

I IIa IIb III

I IIa IIb III

Permanent ventricular pacing is indicated for transient

advanced second- or third-degree infranodal AV block
and associated bundle-branch block. If the site of block
is uncertain, an electrophysiological study may be
necessary.
Permanent ventricular pacing is indicated for persistent
and symptomatic second- or third-degree AV block.

*These recommendations are consistent with the ACC/AHA Guidelines for the Management of Patients 27
with ST-Elevation Myocardial Infarction.

Permanent Pacing in Hypersensitive Carotid

Sinus Syndrome and Neurocardiogenic
Syncope
I IIa IIb III

I IIa IIb III

I IIa IIb III

Permanent pacing is indicated for recurrent

syncope caused by spontaneously occurring
carotid sinus stimulation and carotid sinus
pressure that induces ventricular asystole of more
than 3 seconds.
Permanent pacing is reasonable for syncope
without clear, provocative events and with a
hypersensitive cardioinhibitory response of 3
seconds or longer.
Permanent pacing may be considered for
significantly symptomatic neurocardiogenic
syncope associated with bradycardia documented
spontaneously or at the time of tilt-table testing.
28

Pacing to Prevent Tachycardia

I IIa IIb III

Permanent pacing is indicated for sustained

pause-dependent VT, with or without QT
prolongation.

I IIa IIb III

Permanent pacing is reasonable for highrisk patients with congenital long-QT

syndrome.
I IIa IIb III

Permanent pacing may be considered for

prevention of symptomatic, drug-refractory,
recurrent AF in patients with coexisting
SND.
29

Role of EPS
1. Not indicated for bradycardia per se
2. Syncope of unknown origin + abnormal
SN function
3. HV>100ms in evaluation of syncope in
Chronic bifascicular block
4. Syncope + bifascicular block when VT
cannot be demonstrated [pacing may be
indicated even if HV<100 ms due to low
sensitivity of HV measurement (Class
IIa)]
30

Remote Follow-up and Monitoring (New

section added)
Before 2008- standard approach: routine in-person
office FU supplemented by transtelephonic monitoring
as remote FU
Remote monitoring of cardiovascular implantable
electronic devices (CIEDs)
PM, ICD, CRT, implantable loop recorders, implantable CV
monitors
Bidirectional telemetry with encoded and encrypted RF
signals allowing transmission and receipt of information
from CIEDs
Wireless cellular technology allow links into patients
location

Evolving technology for FU and evidence supporting

its use

Minimum Frequency of CIED In-person or

Remote Monitoring

Pacemaker/ICD/CRT

Method

Within 72hr of CIED implant

In person

2-12 wk postimplantation

In person

Every 3-12 mths for PM/ CRTP

In person or remote

Every 3-6 mths for ICD/CRTD

In person or remote

Annually until battery depletion

In person

Every 1-3 mth at signs of battery depletion

In person or remote

ESC/ EHRA Guidelines 2013Simplified Recommendations

European Heart Journal 2013; 34(29):2281-2329

Guidelines in general suffer from the problem that they are
written by important experts in the field who use a language
that is for experts But guidelines are for non expertsMichele Brignole
Problems of recommendations tend to be too precise and
physicians may have difficulty matching them to daily clinical
situation of a particular patient

Innovative Approach to ESC/EHRA

Guidelines
More general- guidelines are advice rather than rules
If I give advice I can be more general, so that the
physician understands and the advice helps him to make
his own decision

More visibility to differences of opinion

Class II evidence given when there is divergence of opinion

Rate quality of evidence using Grading of

Recommendation Assessment, Development and
Evaluation (GRADE) methodology
further research is very unlikely to change our confidence
in the estimated effect
further research is very likely to have an important impact
on our confidence in the estimated effect

New Insights and Recommendations

Complications of pacemaker therapy

RV pacing sites
Perioperative anticoagulation
Pacing and Magnetic resonance imaging
Remote monitoring

ESC Guidelines 2013

Until now, guidelines have classified bradyarrhythmias

according to aetiology,

for example whether the problem has been

caused by sinus node dysfunction,
myocardial infarction (MI), or bundle branch
block
Current guidelines classification based upon mechanism

What physicians see when they look into

ECG

New Classification of Bradyarrhythmias

Diagnosis of bradycardia and bradycardiasymptom-correlation

Indication for pacing in sick sinus syndrome
and AV block is significantly simplified
Use of implantable loop-recording in syncope
of unknown origin encouraged
Newly defined pacing indications are syncope
in bundle branch block and very long PR
(>300ms), particularly in older patients and
those with structural heart disease

ESC Guidelines 2013

Pacing indications divided into three main groups:
1. Persistent bradycardia
Standard ECG diagnosis

2. Intermittent bradycardia with electrocardiographic

documentation
Standard ECG or more prolonged ECG recordings
(ambulatory monitoring or implantable loop recorder)

3. Suspected intermittent bradycardia (not yet documented)

Provocative testing or electrophysiological study (EPS) may
be required

ESC Guidelines 2013

Diagnosis of Bradyarrhythmic Syncope After Initial Assessment: Most Useful Tests

Suggested ECG Monitoring Techniques Depending on Symptom Frequency

European Heart Journal (2013) 34, 22812329

ESC Guidelines 2013

Classification of bradyarrhythmias based on clinical presentation

European Heart Journal (2013) 34, 22812329

ESC Guidelines 2013

Since there is no defined heart rate below which
treatment is indicated, correlation between symptoms
and bradyarrhythmia is essential when deciding on the
need for cardiac pacing therapy
This can be difficult to establish in patients with
competing mechanisms for their symptoms. In general,
an attempt to obtain ECG documentation during
syncope (symptom-arrhythmia correlation) is warranted

PERSISTENT BRADYCARDIA
Sinus node disease / Acquired AV block

European Heart Journal (2013)

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European Heart Journal (2013)

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INTERMITTENT DOCUMENTED
BRADYCARDIA

Indication for Pacing

B. Pacing is indicated in patients with intermittent
documented bradycardia (sinus bradycardia or AV
block):
Who have documented symptomatic bradycardia due to
sinus arrest or AV block
With third- or second-degree type 2 AV block irrespective
of symptoms
Should be considered in patients 40 years with
recurrent, unpredictable reflex syncope and documented
symptomatic pause/s due to sinus arrest or AV block or
the combination of the two

European Heart Journal (2013)

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European Heart Journal (2013) 34, 22812329

SYNCOPE AND SUSPECTED (

UNDOCUMENTED)
BRADYCARDIA

Indication for Pacing

C. Pacing is indicated in patients with syncope and
suspected (undocumented ) bradycardia:
Alternating BBB and in patients with BBB and positive EPS
defined as HV interval of 70 ms, or second- or third-degree
His-Purkinje block demonstrated during incremental atrial
pacing or with pharmacological challenge
With dominant cardioinhibitory carotid sinus syndrome and
recurrent unpredictable syncope
May be considered in selected patients with unexplained
syncope and BBB
May be indicated in patients with tilt-induced cardioinhibitory
response with recurrent frequent unpredictable syncope and
age >40 years after alternative therapy has failed

BUNDLE BRANCH BLOCK

European Heart Journal (2013)

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UNDOCUMENTED REFLEX
SYNCOPE

European Heart Journal (2013)

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European Heart Journal (2013) 34, 22812329

ESC Guidelines 2013

One of the big innovations of these guidelines is the development
of a logical decision tree displaying the different pacing modes
according to different clinical situations

European Heart Journal (2013)

34, 22812329

More Controversial Issues

Chronotropic Incompetence
Neither diagnostic criteria nor therapeutic indications are
defined and the guidelines propose that the usefulness of CP
should be determined on a case-by-case basis, in contrast with
the US guidelines, which establish a I C indication

Pacing Mode Selection

Although the superiority of the DDD mode over VVI and AAI
modes remains clear, as shown, the indication for DDD pacing
as first choice in all cases of SND without permanent AF
remains controversial

Usefulness of Cardiac Pacing in Vasovagal Syncope

Induced in Tilt-Table Testing With Cardioinhibitory
Response
Due to the contradictory results of published randomized trials,
controversy among experts continues and further research is
needed

Management Consideration
Right Ventricular Pacing From Alternative Sites
Pacing from the right ventricle outflow tract is recognized as an
alternative to pacing from the apex. It does not lead to a greater
incidence of complications, although hemodynamic results an
depend on electrode location; para-Hisian pacing is more
favorable than medioseptal pacing

Reimplantation of Pacemaker and Cardiac

Resynchronization Therapy Devices After Explantation
Due to Infection
In this situation, an indication is made about the advisability of
reimplantation at a site other than the previous location
(contralateral side of the thorax) or of a change to epicardial
pacing, especially in patients undergoing thoracotomy or if
venous access is impossible

Management Consideration

Magnetic Resonance Imaging in Electronic Cardiac Device-Dependent

Patients

The guidelines then suggest that expert monitoring is

needed during the imaging study, a period of 6 weeks
should elapse between cable implantation and any study
for the cables to fix effectively, patients with abandoned
or epicardial cables should be excluded
PM-dependent patients should be programmed in
asynchronous mode and patients without PMdependence in inhibited mode, and that other pacing
functions, especially antitachycardia therapies, should be
deactivated.
All this is presented in an easily-interpreted flowchart. In
patients with magnetic resonance (MR) imaging
compatible devices, users are advised to follow the
manufacturers instructions.

European Heart Journal (2013)

34, 22812329

Management Consideration
Temporary Transvenous Pacing
This is not recommended given the frequent associated
complications. If used, it should be for the minimum period and
PM implantation should take place as early as possible.

Remote Monitoring and Arrhythmias

The guidelines recognize the usefulness of remote monitoring
in the follow-up of patients with CRT devices and in early
diagnosis of AF episodes, especially in asymptomatic patients,
since it permits early administration of anticoagulation therapy
and prevention of stroke (class IIa A indication)