News from the Heart Rhythm SocietyPractice guideline: Executive summaryACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) Developed in Collaboration With the American Association for Thoracic Surgery and Society of Thoracic Surgeons
Section snippets
Table of Contents
Preamble......935
- 1
Introduction......936
- 1.1
Organization of Committee......936
- 1.2
Document Review and Approval......936
- 1.3
Methodology and Evidence......937
- 1.1
- 2
Recommendations for Permanent Pacing in Sinus Node Dysfunction......939
- 3
Recommendations for Acquired Atrioventricular Block in Adults......939
- 4
Recommendations for Permanent Pacing in Chronic Bifascicular Block......942
- 5
Recommendations for Permanent Pacing After the Acute Phase of Myocardial Infarction......943
- 6
Recommendations for Permanent Pacing in
Preamble
It is important that the medical profession play a significant role in critically evaluating the use of diagnostic procedures and therapies as they are introduced and tested in the detection, management, or prevention of disease states. Rigorous and expert analysis of the available data documenting absolute and relative benefits and risks of those procedures and therapies can produce helpful guidelines that improve the effectiveness of care, optimize patient outcomes, and favorably affect the
Class I
- 1
Permanent pacemaker implantation is indicated for sinus node dysfunction (SND) with documented symptomatic bradycardia, including frequent sinus pauses that produce symptoms. (Level of Evidence: C) (9, 10, 11)
- 2
Permanent pacemaker implantation is indicated for symptomatic chronotropic incompetence. (Level of Evidence: C) (9, 10, 11, 12, 13)
- 3
Permanent pacemaker implantation is indicated for symptomatic sinus bradycardia that results from required drug therapy for medical conditions. (Level of
Class I
- 1
Permanent pacemaker implantation is indicated for third-degree and advanced second-degree AV block at any anatomic level associated with bradycardia with symptoms (including heart failure) or ventricular arrhythmias presumed to be due to AV block. (Level of Evidence: C) (15, 19, 20, 21)
- 2
Permanent pacemaker implantation is indicated for third-degree and advanced second-degree AV block at any anatomic level associated with arrhythmias and other medical conditions that require drug therapy that
Class I
- 1
Permanent pacemaker implantation is indicated for advanced second-degree AV block or intermittent third-degree AV block. (Level of Evidence: B) (19, 39, 47, 48, 49, 50, 51)
- 2
Permanent pacemaker implantation is indicated for type II second-degree AV block. (Level of Evidence: B) (52, 53, 54, 55)
- 3
Permanent pacemaker implantation is indicated for alternating bundle-branch block. (Level of Evidence: C) (56)
Class IIa
- 1
Permanent pacemaker implantation is reasonable for syncope not demonstrated to be due to AV
Class I
- 1
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 ST-segment elevation myocardial infarction. (Level of Evidence: B) (54, 75, 76, 77, 78, 79)
- 2
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
Class I
- 1
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. (Level of Evidence: C) (80, 81)
Class IIa
- 1
Permanent pacing is reasonable for syncope without clear, provocative events and with a hypersensitive cardioinhibitory response of 3 seconds or longer. (Level of Evidence: C) (80)
Class IIb
- 1
Permanent pacing may be considered for significantly symptomatic neurocardiogenic syncope
Class I
- 1
Permanent pacing is indicated for persistent inappropriate or symptomatic bradycardia not expected to resolve and for other Class I indications for permanent pacing. (Level of Evidence: C)
Class IIb
- 1
Permanent pacing may be considered when relative bradycardia is prolonged or recurrent, which limits rehabilitation or discharge after postoperative recovery from cardiac transplantation. (Level of Evidence: C)
- 2
Permanent pacing may be considered for syncope after cardiac transplantation even when
Class IIa
- 1
Permanent pacing is reasonable for symptomatic recurrent supraventricular tachycardia that is reproducibly terminated by pacing when catheter ablation and/or drugs fail to control the arrhythmia or produce intolerable side effects. (Level of Evidence: C) (86, 87, 88, 89, 90)
Class III
- 1
Permanent pacing is not indicated in the presence of an accessory pathway that has the capacity for rapid anterograde conduction. (Level of Evidence: C)
Class I
- 1
Permanent pacing is indicated for sustained pause-dependent VT, with or without QT prolongation. (Level of Evidence: C) (91, 92)
Class IIa
- 1
Permanent pacing is reasonable for high-risk patients with congenital long-QT syndrome. (Level of Evidence: C) (91, 92)
Class IIb
- 1
Permanent pacing may be considered for prevention of symptomatic, drug-refractory, recurrent atrial fibrillation in patients with coexisting SND. (Level of Evidence: B) (93, 94, 95, 96)
Class III
- 1
Permanent pacing is not indicated for frequent or complex
Class III
- 1
Permanent pacing is not indicated for the prevention of atrial fibrillation in patients without any other indication for pacemaker implantation. (Level of Evidence: B) (100)
Class I
- 1
For patients who have LV ejection fraction (LVEF) less than or equal to 35%, a QRS duration greater than or equal to 0.12 seconds, and sinus rhythm, CRT with or without an ICD is indicated for the treatment of New York Heart Association (NYHA) functional Class III or ambulatory Class IV heart failure symptoms with optimal recommended medical therapy. (Level of Evidence: A) (101, 101a, 101b, 101c)
Class IIa
- 1
For patients who have LVEF less than or equal to 35%, a QRS duration greater than or equal to 0.12
Class I
- 1
Permanent pacing is indicated for SND or AV block in patients with hypertrophic cardiomyopathy as described previously (see Section 2.1.1, “Sinus Node Dysfunction,” and Section 2.1.2, “Acquired Atrioventricular Block in Adults,” in the full-text guidelines). (Level of Evidence: C)
Class IIb
- 1
Permanent pacing may be considered in medically refractory symptomatic patients with hypertrophic cardiomyopathy and significant resting or provoked LV outflow tract obstruction. (Level of Evidence: A) As for Class I
Class I
- 1
Permanent pacemaker implantation is indicated for advanced second- or third-degree AV block associated with symptomatic bradycardia, ventricular dysfunction, or low cardiac output. (Level of Evidence: C)
- 2
Permanent pacemaker implantation is indicated for SND with correlation of symptoms during age-inappropriate bradycardia. The definition of bradycardia varies with the patient's age and expected heart rate. (Level of Evidence: B) (9, 22, 109, 110)
- 3
Permanent pacemaker implantation is indicated for
Recommendations for Implantable Cardioverter-Defibrillators
Secondary prevention refers to the prevention of SCD in those patients who have survived a prior cardiac arrest or sustained VT. Primary prevention refers to the prevention of SCD in individuals without a history of cardiac arrest or sustained VT. Patients with cardiac conditions associated with a high risk of sudden death who have unexplained syncope that is likely to be due to ventricular arrhythmias are considered to have a secondary indication.
Recommendations for consideration of ICD
Class I
- 1
ICD implantation is indicated in the survivor of cardiac arrest after evaluation to define the cause of the event and to exclude any reversible causes. (Level of Evidence: B) (149, 150, 151, 152)
- 2
ICD implantation is indicated for patients with symptomatic sustained VT in association with congenital heart disease who have undergone hemodynamic and electrophysiological evaluation. Catheter ablation or surgical repair may offer possible alternatives in carefully selected patients. (Level of
Staff
American College of Cardiology Foundation
John C. Lewin, MD, Chief Executive Officer
Charlene May, Senior Director, Clinical Policy and Guidelines
Lisa Bradfield, Associate Director, Practice Guidelines
Mark D. Stewart, MPH, Associate Director, Evidence-Based Medicine
Kristen N. Fobbs, MS, Senior Specialist, Practice Guidelines
Erin A. Barrett, Senior Specialist, Clinical Policy and Guidelines
American Heart Association
M. Cass Wheeler, Chief Executive Officer
Gayle R. Whitman, RN, PhD, FAAN, FAHA, Vice
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Cited by (0)
This document was approved by the American College of Cardiology Foundation Board of Trustees, the American Heart Association Science Advisory and Coordinating Committee, and the Heart Rhythm Society Board of Trustees in February 2008. The American College of Cardiology Foundation, American Heart Association, and Heart Rhythm Society request that this document be cited as follows: Epstein AE, DiMarco JP, Ellenbogen KA, Estes NAM III, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO. ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices). Heart Rhythm 2008;5:0000–0000. This article has been copublished in the May 27, 2008, issue of Circulation and the May 27, issue of J Am Coll Cardiol. Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.acc.org), the American Heart Association (www.americanheart.org), and the Heart Rhythm Society (www.hrsonline.org). For copies of this document, please contact the Elsevier Inc. Reprint Department, fax (212) 633-3820, e-mail [email protected]. Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American College of Cardiology Foundation, American Heart Association, or Heart Rhythm Society. Please contact Elsevier's permission department at [email protected].
- ⁎
Recused from voting on guideline recommendations (see Section 1.2, “Document Review and Approval,” for more detail);
- †
American Association for Thoracic Surgery and Society of Thoracic Surgeons official representative;
- ‡
Heart Failure Society of America official representative
- §
Former Task Force member during this writing effort