General Evaluation
4.1. History and Physical Examination of Patients With Documented or Suspected Bradycardia or Conduction Disorders
1. In patients with suspected bradycardia or conduction disorders a comprehensive history and physical examination should be performed. ( I, C-EO )
Noninvasive Evaluation
4.2.1. Electrocardiogram (ECG) in Patients With Documented or Suspected Bradycardia or Conduction Disorders
1. In patients with suspected bradycardia or conduction disorder, a 12-lead ECG is recommended to document rhythm, rate, and conduction, and to screen for structural heart disease or systemic illness. ( I, B-NR )
Treatment
4.2.2. Exercise Electrocardiographic Testing in Patients With Documented or Suspected Bradycardia or Conduction Disorders
1. In patients with suspected chronotropic incompetence, exercise electrocardiographic testing is reasonable to ascertain the diagnosis and provide information on prognosis. ( IIa, B-NR )
2. In patients with exercise-related symptoms suspicious for bradycardia or conduction disorders, or in patients with 2:1 atrioventricular block of unknown level, exercise electrocardiographic testing is reasonable. ( IIa, C-LD )
4.2.3. Ambulatory Electrocardiography in Patients With Documented or Suspected Bradycardia or Conduction Disorders
1. In the evaluation of patients with documented or suspected bradycardia or conduction disorders, cardiac rhythm monitoring is useful to establish correlation between heart rate or conduction abnormalities with symptoms, with the specific type of cardiac monitor chosen based on the frequency and nature of symptoms, as well as patient preferences. ( I, B-NR )
4.2.4. Cardiac Imaging in Bradycardia or Conduction Disorders
1. In patients with newly identified LBBB, second-degree Mobitz type II atrioventricular block, high-grade atrioventricular block, or third-degree atrioventricular block with or without apparent structural heart disease or coronary artery disease, transthoracic echocardiography is recommended. ( I, B-NR )
2. In selected patients presenting with bradycardia or conduction disorders other than LBBB, second-degree Mobitz type II atrioventricular block, high-grade atrioventricular block, or third-degree atrioventricular block, transthoracic echocardiography is reasonable if structural heart disease is suspected. ( IIa, B-NR )
3. In selected patients with bradycardia or bundle branch block, disease-specific advanced imaging (e.g., transesophageal echocardiography, computed tomography, cardiac magnetic resonance imaging [MRI], or nuclear imaging) is reasonable if structural heart disease is suspected yet not confirmed by other diagnostic modalities. ( IIa, C-LD )
4. In the evaluation of patients with asymptomatic sinus bradycardia or first-degree atrioventricular block and no clinical evidence of structural heart disease, routine cardiac imaging is not indicated. ( III - No Benefit, B-NR )
4.2.5. Laboratory Testing in Patients With Documented or Suspected Bradycardia or Conduction Disorders
1. In patients with bradycardia, laboratory tests (e.g., thyroid function tests, Lyme titer, potassium, pH) based on clinical suspicion for a potential underlying cause are reasonable. ( IIa, C-LD )
4.2.6. Genetic Testing in Documented or Suspected Bradycardia or Conduction Disorders
1. In patients in whom a conduction disorder-causative mutation has been identified, genetic counseling and mutation-specific genetic testing of first-degree relatives is recommended to identify similarly affected individuals. ( I, C-EO )
2. In patients with inherited conduction disease, genetic counseling and targeted testing may be considered to facilitate cascade screening of relatives as part of the diagnostic evaluation. ( IIb, C-EO )
4.2.7. Sleep Apnea Evaluation and Treatment in Patients With Documented or Suspected Bradycardia or Conduction Disorders
1. In patients with documented or suspected bradycardia or conduction disorder during sleep, screening for symptoms of sleep apnea syndrome is recommended with subsequent confirmatory testing directed by clinical suspicion. ( I, B-NR )
2. In patients with sleep-related bradycardia or conduction disorder and documented obstructive sleep apnea, treatment directed specifically at the sleep apnea (e.g., continuous positive airway pressure and weight loss) is recommended. ( I, B-NR )
3. In patients who have previously received or are being considered for a PPM for bradycardia or conduction disorder, screening for sleep apnea syndrome is reasonable. ( IIa, B-NR )
Invasive Testing
4.3.1. Implantable Cardiac Monitor in Patients With Documented or Suspected Bradycardia or Conduction Disorders
1. In patients with infrequent symptoms (>30 days between symptoms) suspected to be caused by bradycardia, long-term ambulatory monitoring with an implantable cardiac monitor (ICM) is reasonable if initial noninvasive evaluation is nondiagnostic. ( IIa, C-LD )
4.3.2. Electrophysiology Testing in Patients With Documented or Suspected Bradycardia or Conduction Disorders
1. In patients with symptoms suspected to be attributable to bradycardia, an electrophysiology study (EPS) may be considered in selected patients for diagnosis of, and elucidation of bradycardia mechanism, if initial noninvasive evaluation is nondiagnostic. ( IIb, C-LD )
Bradycardia Attributable to SND
5.3.1. Acute Management of Reversible Causes for Bradycardia Attributable to SND
1. In symptomatic patients presenting with SND, evaluation and treatment of reversible causes is recommended. ( I, C-EO )
5.3.2.1. Atropine and Beta Agonists for Bradycardia Attributable to SND
1. In patients with
SND associated with symptoms or hemodynamic compromise,
atropine is reasonable to increase sinus rate.
( IIa, C-LD ) 2. In patients with
SND associated with symptoms or hemodynamic compromise who are at low likelihood of coronary ischemia,
isoproterenol,
dopamine,
dobutamine, or
epinephrine may be considered to increase heart rate and improve symptoms.
( IIa, C-LD ) 3. In patients who have undergone heart transplant without evidence for autonomic reinnervation,
atropine should not be used to treat sinus bradycardia.
( III - Harm, C-LD )
5.3.2.2. Therapy of Beta Blocker and Calcium Channel Blocker Mediated Bradycardia
1. In patients with bradycardia associated with symptoms or hemodynamic compromise because of calcium channel blocker overdose, intravenous calcium is reasonable to increase heart rate and improve symptoms. ( IIa, C-LD )
2. In patients with bradycardia associated with symptoms or hemodynamic compromise because of beta-blocker or calcium channel blocker overdose, glucagon is reasonable to increase heart rate and improve symptoms. ( IIa, C-LD )
3. In patients with bradycardia associated with symptoms or hemodynamic compromise because of beta-blocker or calcium channel blocker overdose, high-dose insulin therapy is reasonable to increase heart rate and improve symptoms. ( IIa, C-LD )
5.3.2.3. Therapy of Digoxin Mediated Bradycardia Attributable to either SND or Atrioventricular Block
1. In patients with bradycardia associated with symptoms or hemodynamic compromise in the setting of
digoxin toxicity,
digoxin Fab antibody fragment is reasonable to increase heart rate and improve symptoms.
( IIa, C-LD ) 2. In patients with bradycardia associated with symptoms or hemodynamic compromise attributable to
digoxin toxicity, dialysis is not recommended for removal of
digoxin.
( III - No Benefit, C-LD )
5.3.2.4. Theophylline/Aminophylline for Bradycardia Attributable to SND
1. In post-heart transplant patients, aminophylline or theophylline is reasonable to increase heart rate if clinically indicated. ( IIa, C-LD )
2. In patients with SND associated with symptoms or hemodynamic compromise in the setting of acute spinal cord injury, aminophylline or theophylline is reasonable to increase heart rate and improve symptoms. ( IIa, C-LD )
5.3.3. Temporary Pacing for Bradycardia Attributable to SND
1. In patients with persistent hemodynamically unstable SND refractory to medical therapy, temporary transvenous pacing is reasonable to increase heart rate and improve symptoms until a PPM is placed or the bradycardia resolves. ( IIa, C-LD )
2. In patients with SND with severe symptoms or hemodynamic compromise, temporary transcutaneous pacing may be considered to increase heart rate and improve symptoms until a temporary transvenous or PPM is placed or the bradycardia resolves. ( IIb, C-LD )
3. In patients with SND with minimal and/or infrequent symptoms without hemodynamic compromise, temporary transcutaneous or transvenous pacing should not be performed. ( III - Harm, C-LD )
Invasive Testing
5.4.1. General Principles of Chronic Therapy/Management of Bradycardia Attributable to SND
1. In asymptomatic individuals with sinus bradycardia or sinus pauses that are secondary to physiologically elevated parasympathetic tone, permanent pacing should not be performed. ( III - Harm, C-LD )
2. In patients with sleep-related sinus bradycardia or transient sinus pauses occurring during sleep, permanent pacing should not be performed unless other indication for pacing are present. ( III - Harm, C-LD )
3. In patients with asymptomatic SND, or in those in whom the symptoms have been documented to occur in the absence of bradycardia or chronotropic incompetence, permanent pacing should not be performed. ( III - Harm, C-LD )
5.4.2. Transient/Reversible Causes (Including Medications) of Sinus Bradycardia
1. Patients presenting with symptomatic SND secondary to a reversible cause should first be managed by directing the therapy at eliminating or mitigating the offending condition. ( I, C-EO )
5.4.3. Additional Testing of Bradycardia Attributable to SND
1. In patients with symptoms suggestive of bradycardia (e.g., syncope, lightheadedness) who are also undergoing an EPS for another indication, evaluation of sinus node function as part of the EPS may be considered. ( IIb, C-EO )
2. In symptomatic patients with suspected SND, EPS for the assessment of sinus node function may be considered when the diagnosis remains uncertain after initial noninvasive evaluations. ( IIb, C-EO )
3. In patients with asymptomatic sinus bradycardia, an EPS should not be performed unless other indications for electrophysiological testing exist. ( III - No Benefit, C-LD )
5.4.4. Permanent Pacing for Chronic Therapy/Management of Bradycardia Attributable to SND
1. In patients with symptoms that are directly attributable to SND, permanent pacing is indicated to increase heart rate and improve symptoms. ( I, C-LD )
2. In patients who develop symptomatic sinus bradycardia as a consequence of guideline-directed management and therapy for which there is no alternative treatment and continued treatment is clinically necessary, permanent pacing is recommended to increase heart rate and improve symptoms. ( I, C-EO )
3. For patients with tachy-brady syndrome and symptoms attributable to bradycardia, permanent pacing is reasonable to increase heart rate and reduce symptoms attributable to hypoperfusion. ( IIa, C-EO )
4. In patients with symptomatic chronotropic incompetence, permanent pacing with rate-responsive programming is reasonable to increase exertional heart rates and improve symptoms. ( IIa, C-EO )
5. In patients with symptoms that are likely attributable to SND, a trial of oral theophylline may be considered to increase heart rate, improve symptoms, and help determine the potential effects of permanent pacing. ( IIb, C-LD )
5.4.4.1. Permanent Pacing Techniques and Methods for Chronic Therapy/Management of Bradycardia Attributable to SND
1. In symptomatic patients with SND, atrial-based pacing is recommended over single chamber ventricular pacing. ( I, B-R )
2. In symptomatic patients with SND and intact atrioventricular conduction without evidence of conduction abnormalities, dual chamber or single chamber atrial pacing is recommended. ( I, B-R )
3. In symptomatic patients with SND who have dual chamber pacemakers and intact atrioventricular conduction, it is reasonable to program the dual chamber pacemaker to minimize ventricular pacing. ( IIa, B-R )
4. In symptomatic patients with SND in which frequent ventricular pacing is not expected or the patient has significant comorbidities that are otherwise likely to determine the survival and clinical outcomes, single chamber ventricular pacing is reasonable. ( IIa, C-EO )
Acute Management
6.3.1. Acute Management of Reversible Causes of Bradycardia Attributable to Atrioventricular Block
1. Patients with transient or reversible causes of atrioventricular block, such as Lyme carditis or drug toxicity, should have medical therapy and supportive care, including temporary transvenous pacing if necessary, before determination of need for permanent pacing. ( I, B-R )
2. In selected patients with symptomatic second-degree or third-degree atrioventricular block who are on chronic stable doses of medically necessary
antiarrhythmic or beta-blocker therapy, it is reasonable to proceed to permanent pacing without further observation for drug washout or reversibility.
( IIa, B-R ) 3. In patients with second-degree or third-degree atrioventricular block associated with cardiac sarcoidosis, permanent pacing, with additional defibrillator capability if needed and meaningful survival of greater than 1 year is expected, without further observation for reversibility is reasonable. ( IIa, B-R )
4. In patients with symptomatic second-degree or third-degree atrioventricular block associated with thyroid function abnormalities but without clinical myxedema, permanent pacing without further observation for reversibility may be considered. ( IIb, C-LD )
6.3.2. Acute Medical Therapy for Bradycardia Attributable to Atrioventricular Block
1. For patients with second-degree or third-degree atrioventricular block believed to be at the atrioventricular nodal level associated with symptoms or hemodynamic compromise,
atropine is reasonable to improve atrioventricular conduction, increase ventricular rate, and improve symptoms.
( IIa, C-LD ) 2. For patients with second-degree or third-degree atrioventricular block associated with symptoms or hemodynamic compromise and who have low likelihood for coronary ischemia, beta-adrenergic agonists, such as
isoproterenol,
dopamine,
dobutamine, or
epinephrine, may be considered to improve atrioventricular conduction, increase ventricular rate, and improve symptoms.
( IIb, B-R ) 3. For patients with second-degree or third-degree atrioventricular block associated with symptoms or hemodynamic compromise in the setting of acute inferior MI, intravenous aminophylline may be considered to improve atrioventricular conduction, increase ventricular rate, and improve symptoms. ( IIb, C-LD )
6.3.3. Temporary Pacing for Bradycardia Attributable to Atrioventricular Block
1. For patients with second-degree or third-degree atrioventricular block associated with symptoms or hemodynamic compromise that is refractory to medical therapy, temporary transvenous pacing is reasonable to increase heart rate and improve symptoms. ( IIa, B-R )
2. For patients who require prolonged temporary transvenous pacing, it is reasonable to choose an externalized permanent active fixation lead over a standard passive fixation temporary pacing lead. ( IIa, B-R )
3. For patients with second-degree or third-degree atrioventricular block and hemodynamic compromise refractory to antibradycardic medical therapy, temporary transcutaneous pacing may be considered until a temporary transvenous or PPM is placed or the bradyarrhythmia resolves. ( IIb, B-R )
6.4.1. General Principles of Chronic Therapy/Management of Bradycardia Attributable to Atrioventricular Block
1. In patients with first-degree atrioventricular block or second-degree Mobitz type I (Wenckebach) or 2:1 atrioventricular block which is believed to be at the level of the atrioventricular node, with symptoms that do not temporally correspond to the atrioventricular block, permanent pacing should not be performed. ( III - Harm, C-LD )
2. In asymptomatic patients with first-degree atrioventricular block or second-degree Mobitz type I (Wenckebach) or 2:1 atrioventricular block which is believed to be at the level of the atrioventricular node, permanent pacing should not be performed. ( III - Harm, C-LD )
6.4.2. Potentially Reversible or Transient Causes of Atrioventricular Block
1. In patients with symptomatic atrioventricular block attributable to a known reversible cause in whom the atrioventricular block does not resolve despite treatment of the underlying cause, permanent pacing is recommended. ( I, C-LD )
2. In patients who had acute atrioventricular block attributable to a known reversible and nonrecurrent cause, and have had complete resolution of the atrioventricular block with treatment of the underlying cause, permanent pacing should not be performed. ( III - Harm, C-LD )
3. In patients with asymptomatic vagally mediated atrioventricular block, permanent pacing should not be performed. ( III - Harm, C-LD )
6.4.3. Additional Testing for Chronic Therapy/Management of Bradycardia Attributable to Atrioventricular Block
1. In patients with symptoms (e.g., lightheadedness, dizziness) of unclear etiology who have first-degree atrioventricular block or second-degree Mobitz type I atrioventricular block on ECG, ambulatory electrocardiographic monitoring is reasonable to establish correlation between symptoms and rhythm abnormalities. ( IIa, B-R )
2. In patients with exertional symptoms (e.g., chest pain, shortness of breath) who have first-degree or second-degree Mobitz type I atrioventricular block at rest, an exercise treadmill test is reasonable to determine whether they may benefit from permanent pacing. ( IIa, C-LD )
3. In selected patients with second-degree atrioventricular block, an EPS may be considered to determine the level of the block and to determine whether they may benefit from permanent pacing. ( IIb, B-NR )
4. In selected patients with second-degree atrioventricular block, carotid sinus massage and/or pharmacological challenge with
atropine,
isoproterenol, or
procainamide may be considered to determine the level of the block and to determine whether they may benefit from permanent pacing.
( IIb, C-LD )
6.4.4. Permanent Pacing for Chronic Therapy/Management of Bradycardia Attributable to Atrioventricular Block
1. In patients with acquired second-degree Mobitz type II atrioventricular block, high-grade atrioventricular block, or third degree atrioventricular block not attributable to reversible or physiologic causes, permanent pacing is recommended regardless of symptoms. ( I, B-NR )
2. In patients with neuromuscular diseases associated with conduction disorders, including muscular dystrophy (e.g., myotonic dystrophy type 1) or Kearns-Sayre syndrome, who have evidence of second-degree atrioventricular block, third-degree atrioventricular block, or an HV interval of 70 ms or greater, regardless of symptoms, permanent pacing, with additional defibrillator capability if needed and meaningful survival of greater than 1 year is expected, is recommended. ( I, B-NR )
3. In patients with permanent AF and symptomatic bradycardia, permanent pacing is recommended. ( I, C-LD )
4. In patients who develop symptomatic atrioventricular block as a consequence of guideline-directed management and therapy for which there is no alternative treatment and continued treatment is clinically necessary, permanent pacing is recommended to increase heart rate and improve symptoms. ( I, C-LD )
5. In patients with an infiltrative cardiomyopathy, such as cardiac sarcoidosis or amyloidosis, and second-degree Mobitz type II atrioventricular block, high-grade atrioventricular block, or third-degree atrioventricular block, permanent pacing, with additional defibrillator capability if needed and meaningful survival of greater than 1 year is expected, is reasonable. ( IIa, B-NR )
6. In patients with lamin A/C gene mutations, including limb-girdle and Emery Dreifuss muscular dystrophies, with a PR interval greater than 240 ms and LBBB, permanent pacing, with additional defibrillator capability if needed and meaningful survival of greater than 1 year is expected, is reasonable. ( IIa, B-NR )
7. In patients with marked first-degree or second-degree Mobitz type I (Wenckebach) atrioventricular block with symptoms that are clearly attributable to the atrioventricular block, permanent pacing is reasonable. ( IIa, C-LD )
8. In patients with neuromuscular diseases, such as myotonic dystrophy type 1, with a PR interval greater than 240 ms, a QRS duration greater than 120 ms, or fascicular block, permanent pacing, with additional defibrillator capability if needed and meaningful survival of greater than 1 year is expected, may be considered. ( IIb, C-LD )
6.4.4.1. Permanent Pacing Techniques and Methods for Chronic Therapy/Management of Bradycardia Attributable to Atrioventricular Block
1. In patients with SND and atrioventricular block who require permanent pacing, dual chamber pacing is recommended over single chamber ventricular pacing. ( I, A )
2. In select patients with atrioventricular block who require permanent pacing in whom frequent ventricular pacing is not expected, or who have significant comorbidities that are likely to determine clinical outcomes and that may limit the benefit of dual chamber pacing, single chamber ventricular pacing is effective. ( I, A )
3. For patients in sinus rhythm with a single chamber ventricular pacemaker who develop pacemaker syndrome, revising to a dual chamber pacemaker is recommended. ( I, B-R )
4. In patients with atrioventricular block who have an indication for permanent pacing with a LVEF between 36% and 50% and are expected to require ventricular pacing more than 40% of the time, it is reasonable to choose pacing methods that maintain physiologic ventricular activation (e.g., cardiac resynchronization therapy [CRT] or His bundle pacing) over right ventricular pacing. ( IIa, B-R )
5. In patients with atrioventricular block who have an indication for permanent pacing with a LVEF between 36% and 50% and are expected to require ventricular pacing less than 40% of the time, it is reasonable to choose right ventricular pacing over pacing methods that maintain physiologic ventricular activation (e.g., CRT or His bundle pacing). ( IIa, B-R )
6. In patients with atrioventricular block at the level of the atrioventricular node who have an indication for permanent pacing, His bundle pacing may be considered to maintain physiologic ventricular activation. ( IIb, B-R )
7. In patients with permanent or persistent AF in whom a rhythm control strategy is not planned, implantation of an atrial lead should not be performed. ( III - Harm, C-LD )
Conduction Disorders (With 1:1 Atrioventricular Conduction)
7.4. Evaluation of Conduction Disorders (With 1:1 Atrioventricular Conduction and Normal PR Interval)
1. In patients with newly detected LBBB, a transthoracic echocardiogram to exclude structural heart disease is recommended. ( I, B-NR )
2. In symptomatic patients with conduction system disease, in whom atrioventricular block is suspected, ambulatory electrocardiographic monitoring is useful. ( I, C-LD )
3. In selected patients presenting with intraventricular conduction disorders other than LBBB, transthoracic echocardiography is reasonable if structural heart disease is suspected. ( IIa, B-NR )
4. In patients with symptoms suggestive of intermittent bradycardia (e.g., lightheadedness, syncope), with conduction system disease identified by ECG and no demonstrated atrioventricular block, an EPS is reasonable. ( IIa, B-NR )
5. In selected patients with LBBB in whom structural heart disease is suspected and echocardiogram is unrevealing, advanced imaging (e.g., cardiac MRI, computed tomography, or nuclear studies) is reasonable. ( IIa, C-LD )
6. In selected asymptomatic patients with extensive conduction system disease (bifascicular or trifascicular block), ambulatory electrocardiographic recording may be considered to document suspected higher degree of atrioventricular block. ( IIb, C-LD )
7. In selected asymptomatic patients with LBBB in whom ischemic heart disease is suspected, stress testing with imaging may be considered. ( IIb, C-LD )
7.5. Management of Conduction Disorders (With 1:1 Atrioventricular Conduction and Normal PR Intervals)
1. In patients with syncope and bundle branch block who are found to have an HV interval 70 ms or greater or evidence of infranodal block at EPS, permanent pacing is recommended. ( I, C-LD )
2. In patients with alternating bundle branch block, permanent pacing is recommended. ( I, C-LD )
3. In patients with Kearns-Sayre syndrome and conduction disorders, permanent pacing is reasonable, with additional defibrillator capability if appropriate and meaningful survival of greater than 1 year is expected. ( IIa, C-LD )
4. In patients with Anderson-Fabry disease and QRS prolongation greater than 110 ms, permanent pacing, with additional defibrillator capability if needed and meaningful survival of greater than 1 year is expected, may be considered. ( IIb, C-LD )
5. In patients with heart failure, a mildly to moderately reduced LVEF (36%–50%), and LBBB (QRS ≥150 ms), CRT may be considered. ( IIb, C-LD )
6. In asymptomatic patients with isolated conduction disease and 1:1 atrioventricular conduction, permanent pacing is not indicated (in the absence of other indications for pacing). ( III - Harm, B-NR )
Special Populations
8.1.1. Patients at Risk for Bradycardia During Noncardiac Surgery or Procedures
1. In patients who are thought to be at high risk for the development of intraoperative or periprocedural bradycardia because of patient characteristics or procedure type, placement of transcutaneous pacing pads is reasonable. ( IIa, B-NR )
2. In patients with LBBB who require pulmonary artery catheterization for intraoperative monitoring, routine prophylactic temporary transvenous pacing should not be performed. ( III - Harm, B-NR )
8.1.2.1. Pacing After Isolated Coronary Artery Bypass Surgery
1. In patients who have new postoperative SND or atrioventricular block associated with persistent symptoms or hemodynamic instability that does not resolve after isolated coronary artery bypass surgery, permanent pacing is recommended before discharge. ( I, B-NR )
2. In patients undergoing isolated coronary artery bypass surgery, routine placement of temporary epicardial pacing wires is reasonable. ( IIa, B-NR )
3. In patients undergoing coronary artery bypass surgery who will likely require future CRT or ventricular pacing, intraoperative placement of a permanent epicardial left ventricular lead may be considered. ( IIb, C-EO )
8.1.2.2. Pacing After Surgery for Atrial Fibrillation
1. In patients undergoing surgery for AF, routine placement of temporary epicardial pacing wires is recommended. ( I, B-NR )
2. In patients who have new postoperative SND or atrioventricular block associated with symptoms or hemodynamic instability that does not resolve after surgery for AF, permanent pacing is recommended before discharge. ( I, B-NR )
3. In patients undergoing surgery for AF who will likely require future CRT or ventricular pacing, intraoperative placement of a permanent epicardial left ventricular lead may be considered. ( IIb, C-EO )
8.1.2.3.1. Pacing After Aortic Valve Surgery
1. In patients undergoing surgical aortic valve replacement or repair, routine placement of temporary epicardial pacing wires is recommended. ( I, C-LD )
2. In patients who have new postoperative SND or atrioventricular block associated with persistent symptoms or hemodynamic instability that does not resolve after aortic valve replacement, permanent pacing is recommended before discharge. ( I, B-NR )
3. In patients undergoing aortic valve surgery who will likely require future CRT or ventricular pacing, intraoperative placement of a permanent epicardial left ventricular lead may be considered. ( IIb, C-EO )
8.1.2.3.2. Pacing After Mitral Valve Surgery
1. In patients who have new postoperative SND or atrioventricular block associated with persistent symptoms or hemodynamic instability that does not resolve after mitral valve repair or replacement surgery, permanent pacing is recommended before discharge. ( I, B-NR )
2. In patients undergoing mitral valve surgery, routine placement of temporary epicardial pacing wires is reasonable. ( IIa, C-LD )
3. In patients undergoing surgical mitral valve repair or replacement who will likely require future CRT or ventricular pacing, intraoperative placement of a permanent epicardial left ventricular lead may be considered. ( IIb, C-EO )
8.1.2.3.3. Pacing After Tricuspid Valve Surgery
1. In patients undergoing tricuspid valve surgery, routine placement of temporary epicardial pacing wires is recommended. ( I, C-LD )
2. In patients who have new postoperative SND or atrioventricular block associated with symptoms or hemodynamic instability that does not resolve after tricuspid valve surgery, permanent pacing is recommended before discharge. ( I, B-NR )
3. In patients who are undergoing tricuspid valve replacement or tricuspid repair with high risk for postoperative atrioventricular block, intraoperative placement of permanent epicardial leads at the time of cardiac surgery is reasonable. ( IIa, C-LD )
8.1.2.4. Conduction Disturbances After Transcatheter Aortic Valve Replacement
1. In patients who have new atrioventricular block after transcatheter aortic valve replacement associated with symptoms or hemodynamic instability that does not resolve, permanent pacing is recommended before discharge. ( I, B-NR )
2. In patients with new persistent bundle branch block after transcatheter aortic valve replacement, careful surveillance for bradycardia is reasonable. ( IIa, B-NR )
3. In patients with new persistent LBBB after transcatheter aortic valve replacement, implantation of a PPM may be considered. ( IIb, B-NR )
8.1.2.5.2. Patients Undergoing Surgical Myectomy or Alcohol Septal Ablation for Hypertrophic Cardiomyopathy
1. In patients with second-degree Mobitz type II atrioventricular block, high-grade atrioventricular block, or persistent complete atrioventricular block after alcohol septal ablation or surgical myectomy, permanent pacing is recommended before discharge. ( I, B-NR )
2. In selected patients with hypertrophic cardiomyopathy who require permanent pacing for rate support after alcohol septal ablation or surgical myectomy and are at high risk for sudden cardiac death and meaningful survival of greater than 1 year is expected, selecting a device with defibrillator capabilities is reasonable. ( IIa, B-NR )
3. In patients with hypertrophic cardiomyopathy who undergo alcohol septal ablation and who are at risk for developing late atrioventricular block, prolonged ambulatory electrocardiographic monitoring may be considered. ( IIb, C-LD )
4. In patients with hypertrophic cardiomyopathy, evaluation of ventriculoatrial conduction by EPS at the time of alcohol septal ablation may be considered for identifying future risk of atrioventricular block. ( IIb, C-LD )
8.2. Management of Bradycardia in Adults With Adult Congenital Heart Disease
1. In adults with adult congenital heart disease (ACHD) and symptomatic SND or chronotropic incompetence, atrial based permanent pacing is recommended. ( I, B-NR )
2. In adults with ACHD and symptomatic bradycardia related to atrioventricular block, permanent pacing is recommended. ( I, B-NR )
3. In adults with congenital complete atrioventricular block with any symptomatic bradycardia, a wide QRS escape rhythm, mean daytime heart rate below 50 bpm, complex ventricular ectopy, or ventricular dysfunction, permanent pacing is recommended. ( I, B-NR )
4. In adults with ACHD and postoperative second-degree Mobitz type II atrioventricular block, high-grade atrioventricular block, or third-degree atrioventricular block that is not expected to resolve, permanent pacing is recommended. ( I, B-NR )
5. In asymptomatic adults with congenital complete atrioventricular block, permanent pacing is reasonable. ( IIa, B-NR )
6. In adults with repaired ACHD who require permanent pacing for bradycardic indications, a bradycardia device with atrial antitachycardia pacing capabilities is reasonable. ( IIa, B-NR )
7. In adults with ACHD with preexisting sinus node and/or atrioventricular conduction disease who are undergoing cardiac surgery, intraoperative placement of epicardial permanent pacing leads is reasonable. ( IIa, C-EO )
8. In adults with ACHD and pacemakers, atrial-based permanent pacing for the prevention of atrial arrhythmias may be considered. ( IIb, B-NR )
9. In selected adults with ACHD and venous to systemic intracardiac shunts, placement of endocardial pacing leads is potentially harmful. ( III - Harm, B-NR )
8.3. Management of Bradycardia in the Context of Acute MI
1. In patients presenting with an acute MI, temporary pacing is indicated for medically refractory symptomatic or hemodynamically significant bradycardia related to SND or atrioventricular block. ( I, B-NR )
2. Patients who present with SND or atrioventricular block in the setting of an acute MI should undergo a waiting period before determining the need for permanent pacing. ( I, B-NR )
3. In patients presenting with an acute MI with second degree Mobitz type II atrioventricular block, high-grade atrioventricular block, alternating bundle-branch block, or third-degree atrioventricular block (persistent or infranodal), permanent pacing is indicated after a waiting period. ( I, B-NR )
4. In patients with an acute
MI with symptomatic or hemodynamically significant sinus bradycardia or atrioventricular block at the level of the atrioventricular node, the administration of
atropine is reasonable.
( IIa, B-NR ) 5. In patients with an acute MI and transient atrioventricular block that resolves, permanent pacing should not be performed. ( III - Harm, B-NR )
6. In patients with an acute MI and a new bundle-branch block or isolated fascicular block in the absence of second-degree or third-degree atrioventricular block, permanent pacing should not be performed. ( III - Harm, B-NR )
8.4.1. Patients With Epilepsy and Symptomatic Bradycardia
1. In patients with epilepsy associated with severe symptomatic bradycardia (ictal bradycardia) where
antiepileptic medications are ineffective, permanent pacing is reasonable for reducing the severity of symptoms.
( IIa, C-LD )
Other Recommendations
9. Management of Bradycardia and Conduction Tissue Disease in Patients Who Require Pacing Therapy and May Also Be at Risk for Ventricular Arrhythmias
1. In patients who require permanent pacing therapy, before implantation, an assessment of the risk of future ventricular arrhythmias and need for an ICD should be performed. ( I, B-NR )
11. Shared Decision-Making for Pacemaker Implantation in the Setting of Guideline-Based Indications for Bradycardia Pacing
1. In patients with symptomatic bradycardia or conduction disorder, clinicians and patients should engage in a shared decision-making approach in which treatment decisions are based not only on the best available evidence, but also on the patient’s goals of care, preferences, and values. ( I, C-LD )
2. Patients considering implantation of a pacemaker or with a pacemaker that requires lead revision or generator change should be informed of procedural benefits and risks, including the potential short and long-term complications and possible alternative therapy, if any, in light of their goals of care, preferences, and values. ( I, C-LD )
3. In patients with indications for permanent pacing but also with significant comorbidities such that pacing therapy is unlikely to provide meaningful clinical benefit, or if patient goals of care strongly preclude pacemaker therapy, implantation or replacement of a pacemaker should not be performed. ( III - No Benefit, C-LD )
13. Discontinuation of Pacemaker Therapy
1. In patients who present for pacemaker pulse generator replacement, or for management of pacemaker related complications, in whom the original pacing indication has resolved or is in question, discontinuation of pacemaker therapy is reasonable after evaluation of symptoms during a period of monitoring while pacing therapy is off. ( IIa, C-LD )
Class of Recommendations and Level of Evidence
COR and LOE are determined independently (any COR may be paired with any LOE).
A recommendation with LOE C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.
* The outcome or result of the intervention should be specified (an improved clinical outcome or increased diagnostic accuracy or incremental prognostic information).
† For comparative-effectiveness recommendations (COR I and IIa; LOE A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.
‡ The method of assessing quality is evolving, including the application of standardized, widely used, and preferably validated evidence grading tools; and for systematic reviews, the incorporation of an Evidence Review Committee.
COR indicates Class of Recommendation; EO, expert opinion; LD, limited data; LOE, Level of Evidence; NR, nonrandomized; R, randomized; RCT, randomized controlled trial.