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Kusumoto FM et al.
Amer Coll Cardiol 2018 Nov 6
An update to the 2008 guidelines
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Sponsoring Organizations: American College of Cardiology, American Heart Association, and Heart Rhythm Society
Target Audience: General cardiologists and cardiac electrophysiologists
Background and Objective
This guideline updates the 2008 bradycardia guidelines from these organizations.
Key Points
- Sinus node dysfunction is most often related to age-dependent progressive fibrosis. Pacing should be limited to those with symptoms due to bradycardia.
- Nocturnal bradycardia is common, and physicians should evaluate these patients for sleep apnea. Pacing is not usually needed.
- Patients with left bundle branch block (LBBB) should be evaluated for structural heart disease, with at least an echocardiogram.
- Even if asymptomatic, patients with irreversible second-degree Mobitz type II atrioventricular block or higher-degree block should be paced. Patients with Wenckebach block should be paced only if they have symptoms due to bradycardia.
- For patients with left ventricular ejection fraction between 36% and 50% who will be paced >40% of the time, cardiac resynchronization therapy or His bundle pacing are recommended.
- LBBB induced by transcatheter aortic-valve replacement (TAVR) is given a class IIb indication for pacing (i.e., might be considered; a weak recommendation), although the authors acknowledge that we need more information.
- Patients or their legally defined surrogates have the right to refuse implantation of permanent pacemakers and to withdraw pacing, even if life threatening.
What’s Changed
Little has changed with pacing since the last guidelines, except for the recommendations for His bundle pacing, which may be appropriate in patients requiring frequent ventricular pacing, and greater patient autonomy in refusing pacing and in withdrawal of pacing, regardless of the effect on life.
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COMMENT
The advent of His bundle pacing has the hope, as-yet unrealized, that this therapy will prevent cardiomyopathy induced by right ventricular pacing. Symptoms are required for pacing in the vast majority of indications, with the exception of Mobitz II atrioventricular block and higher-degree heart block. Indications for pacing post-TAVR are incompletely known.