ACC/AHA Guidelines for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices

JACC Vol. 31, No. 5 April 1998: 1175-1209
ACC/AHA PRACTICE GUIDELINES
ACC/AHA Guidelines for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices
A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Pacemaker Implantation)
COMMITTEE MEMBERS
GABRIEL GREGORATORS, MD, FACC, Chair
MELVIN D. CHEITLIN, MD, FACC		ROGER A. FREEDMAN, MD, FACC
ALICIA CONILL, MD, FACP*		MARK A. HLATKY, MD, FACC
ANDREW E. EPSTEIN, MD, FACC		GERALD V. NACCARELLI, MD, FACC
CHRISTOPHER FELLOWS, MD, FACC		SANJEEV SAKSENA, MD, MBBS, FACC***
T. BRUCE FERGUSON, Jr., MD, FACC**		ROBERT C. SCHLANT, MD, FACC
MICHAEL J. SILKA, MD, FACC
TASK FORCE MEMBERS
	JAMES L. RITCHIE, MD, FACC, Chair RAYMOND J. GIBBONS, MD, FACC, Vice Chair MELVIN D. CHEITLIN, MD, FACC KIM A. EAGLE, MD, FACC TIMOTHY J. GARDNER, MD, FACC RICHARD P. LEWIS, MD, FACC ROBERT A. O'ROURKE, MD, FACC THOMAS J. RYAN, MD, FACC ARTHUR GARSON, Jr., MD, MPH, FACC

*Representative of the American College of Physicians. **Representative of the Society of Thoracic Surgeons. ***Representative of the North American Society of Pacing and Electrophysiology (NASPE).

Address for reprints: A single reprint of this document (the complete Guidelines) is available by calling (US only) or writing the American College of Cardiology, Educational Services, 9111 Old Georgetown Road, Bethesda, MD . Ask for reprint No. 71-0137. To obtain a reprint of the shorter version (Executive Summary) published in the April 7, 1998 issue of Circulation, ask for reprint No. 71-0136. To purchase additional reprints, specify version and reprint number: up to 999 copies, call (US only) or fax ; 1000 or more copies, call , fax , or E-mail pubauth.

Condensed from the above referenced publication.
Updated: 26 Nov 2000

Class I:	Conditions for which there is evidence and/or general agreement that a given procedure or treatment is beneficial, useful, and effective.
Class II:	Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.
	Class IIa:	Weight of evidence/opinion is in favor of usefulness/efficacy.
	Class IIb:	Usefulness/efficacy is less well established by evidence/opinion.
Class III:	Conditions for which there is evidence and/or general agreement that a procedure/treatment is not useful/effective and in some cases may be harmful.

Level of evidence:
    A = data derived from multiple randomized clinical trials involving a large
    number of individuals.
    B = data derived from a limited number of trials involving a comparatively
    small number of patients or from well-designed data analyses of nonrandom-
    ized studies or observational data registries.
    C = the consensus opinion of experts was the primary source of recommendation.

I. Indications for Permanent Pacing

Class I
	1.	Third-degree AV block at any anatomic level, associated with any one of the following conditions:
		a.	Bradycardia with symptoms presumed to be due to AV block. (Level of evidence: C)
		b.	Arrhythmias and other medical conditions that require drugs that result in symptomatic bradycardia. (Level of evidence: C)
		c.	Documented periods of asystole >/= 3.0 seconds or any escape rate >40 beats per minute (bpm) in awake, symptom-free patients. (Level of evidence: B, C)
		d.	After catheter ablation of the AV junction. (Level of evidence: B, C) There are no trials to assess outcome without pacing, and pacing is virtually always planned in this situation unless the operative procedure is AV junction modification.
		e.	Postoperative AV block that is not expected to resolve. (Level of evidence: C)
		f.	Neuromuscular diseases with AV block such as myotonic muscular dystrophy, Kearn-Sayre syndrome, Erb's dystrophy (limb-girdle), and peroneal muscular atrophy. (Level of evidence: B)
	2.	Second-degree AV block regardless of type or site of block, with associated symptomatic bradycardia. (Level of evidence: B)
Class IIa
	1.	Asymptomatic third-degree AV block at any anatomic site with average awake ventricular rates of 40 bpm or faster. (Level of evidence: B, C)
	2.	Asymptomatic type II second-degree AV block. (Level of evidence: B)
	3.	Asymptomatic type I second-degree AV block at intra- or infra-His levels found incidentally at electrophysiological study performed for other indications. (Level of evidence: B)
	4.	First-degree AV block with symptoms suggestive of pacemaker syndrome and documented alleviation of symptoms with temporary AV pacing. (Level of evidence: B)
Class IIb
	1.	Marked first-degree AV block (>0.30 second) in patients with LV dysfunction and symptoms of congestive heart failure in whom a shorter AV interval results in hemodynamic improvement, presumably by decreasing left atrial filling pressure. (Level of evidence: C)
Class III
	1.	Asymptomatic first-degree AV block. (Level of evidence: B)
	2.	Asymptomatic type I second-degree AV block at the supra-His (AV node) level or not known to be intra- or infra-Hisian. (Level of evidence: B, C)
	3.	AV block expected to resolve and unlikely to recur (e.g., drug toxicity, Lyme disease). (Level of evidence: B)

Indications for Permanent Pacing in Chronic
Bifascicular and Trifascicular Block

Class I
	1.	Intermittent third-degree AV block. (Level of evidence: B)
	2.	Type II second-degree AV block. (Level of evidence: B)
Class IIa
	1.	Syncope not proved to be due to AV block when other likely causes have been excluded, specifically ventricular tachycardia (VT). (Level of evidence: B)
	2.	Incidental finding at electrophysiological study of markedly prolonged HV interval (>/= 100 milliseconds) in asymptomatic patients. (Level of evidence: B)
	3.	Incidental finding at electrophysiological study of pacing-induced infra-His block that is not physiological. (Level of evidence: B)
Class IIb
	None
Class III
	1.	Fascicular block without AV block or symptoms. (Level of evidence: B)
	2.	Fascicular block with first-degree AV block without symptoms. (Level of evidence: B)

C. Pacing for Atrioventricular Block Associated With Acute Myocardial Infarction

Indications for Permanent Pacing after the Acute Phase of
Myocardial Infarction*

Class I
	1.	Persistent second-degree AV block in the His-Purkinje system or third-degree AV block within or below the His-Purkinje system after AMI. (Level of evidence: B)
	2.	Transient advanced (second- or third-degree) intra-nodal AV block and associate bundle branch block. If the site of block is uncertain, an electrophysiology study may be necessary. (Level of evidence: B)
	3.	Persistent and symptomatic second- or third-degree AV block. (Level of evidence: C)
Class IIa
	None
Class IIb
	1.	Persistent second- or third-degree AV block at the AV node level. (Level of evidence: B)
Class III
	1.	Transient AV block in the absence of intraventricular conduction defects. (Level of evidence: B)
	2.	Transient AV block in the presence of isolated left anterior fascicular block. (Level of evidence: B)
	3.	Acquired left anterior fascicular block in the absence of AV block. (Level of evidence: B)
	4.	Persistent first-degree AV block in the presence of bundle branch block that is old or age indeterminate. (Level of evidence: B)
*These recommendations generally follow the ACC/AHA Guidelines for Management of Patients With Acute Myocardial Infarction.

Class I
	1.	Sinus node dysfunction with documented symptomatic bradycardia, including frequent sinus pauses that produce symptoms. In some patients, bradycardia is iatrogenic and will occur as a consequence of essential long-term drug therapy of a type and dose for which there are no acceptable alternatives. (Level of evidence: C)
	2.	Symptomatic chronotropic incompetence. (Level of evidence: C)
Class IIa
	1.	Sinus node dysfunction occurring spontaneously or as a result of necessary drug therapy, with heart rate <40 bpm when a clear association between significant symptoms consistent with bradycardia and the actual presence of bradycardia has not been documented. (Level of evidence: C)
Class IIb
	1.	In minimally symptomatic patients, chronic heart rate <30 bpm while awake. (Level of evidence: C)
Class III
	1.	Sinus node dysfunction in asymptomatic patients, including those in whom substantial sinus bradycardia (heart rate <40 bpm) is a consequence of long-term drug treatment.
	2.	Sinus node dysfunction in patients with symptoms suggestive of bradycardia that are clearly documented as not associated with a slow heart rate.
	3.	Sinus node dysfunction with symptomatic bradycardia due to nonessential drug therapy.

Indications for Permanent Pacemakers That Automatically Detect and Pace
to Terminate Tachycardias

Class I
	1.	Symptomatic recurrent supraventricular tachycardia that is reproducibly terminated by pacing after drugs and catheter ablation fail to control the arrhythmia or produce intolerable side effects. (Level of evidence: C)
	2.	Symptomatic recurrent sustained VT as part of an automatic defibrillator system. (Level of evidence: B)
Class IIa
	None
Class IIb
	1.	Recurrent supraventricular tachycardia or atrial flutter that is reproducibly terminated by pacing as an alternative to drug therapy or ablation. (Level of evidence: C)
Class III
	1.	Tachycardias frequently accelerated or converted to fibrillation by pacing.
	2.	The presence of accessory pathways with the capacity for rapid anterograde conduction whether or not the pathways participate in the mechanism of the tachycardia.
Pacing Indications to Prevent Tachycardia
Class I
	1.	Sustained pause-dependent VT, with or without prolonged QT, in which the efficacy of pacing is thoroughly documented. (Level of evidence: C)
Class IIa
	1.	High-risk patients with congenital long QT syndrome. (Level of evidence: C)
Class IIb
	1.	AV reentrant or AV node reentrant supraventricular tachycardia not responsive to medical or ablative therapy. (Level of evidence: C)
	2.	Prevention of symptomatic, drug-refractory, recurrent atrial fibrillation. (Level of evidence: C)
Class III
	1.	Frequent or complex ventricular ectopic activity without sustained VT in the absence of the long QT syndrome.
	2.	Long QT syndrome due to reversible causes.

Indications for Permanent Pacing in Hypersensitive Carotid Sinus Syndrome
and Neurally Mediated Syncope

Class I
	1.	Recurrent syncope caused by carotid sinus stimulation; minimal carotid sinus pressure induces ventricular asystole of >3 seconds' duration in the absence of any medication that depresses the sinus node or AV conduction. (Level of evidence: C)
Class IIa
	1.	Recurrent syncope without clear, provocative events and with a hypersensitive cardioinhibitory response. (Level of evidence: C)
	2.	Syncope of unexplained origin when major abnormalities of sinus node function or AV conduction are discovered or provoked in electrophysiological studies. (Level of evidence: C)
Class IIb
	1.	Neurally mediated syncope with significant bradycardia reproduced by a head-up tilt with or without isoproterenol or other provocative maneuvers. (Level of evidence: B)
Class III
	1.	A hyperactive cardioinhibitory response to carotid sinus stimulation in the absence of symptoms.
	2.	A hyperactive cardioinhibitory response to carotid sinus stimulation in the presence of vague symptoms such as dizziness, light-headedness, or both.
	3.	Recurrent syncope, light-headedness, or dizziness in the absence of a hyperactive cardioinhibitory response.
	4.	Situational vasovagal syncope in which avoidance behavior is effective.

Class I
	1.	Advanced second- or third-degree AV block associated with symptomatic bradycardia, congestive heart failure, or low cardiac output. (Level of evidence: C)
	2.	Sinus node dysfunction 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)
	3.	Postoperative advanced second- or third-degree AV block that is not expected to resolve or persists at >7 days after cardiac surgery. (Level of evidence: B)
	4.	Congenital third-degree AV block with a wide QRS escape rhythm or ventricular dysfunction. (Level of evidence: B)
	5.	Congenital third-degree AV block in the infant with a ventricular rate <50 to 55 bpm or with congenital heart disease and a ventricular rate <70 bpm. (Level of evidence: B, C)
	6.	Sustained pause-dependent VT, with or without prolonged QT, in which the efficacy of pacing is thoroughly documented. (Level of evidence: B)
Class IIa
	1.	Bradycardia-tachycardia syndrome with the need for long-term antiarrhythmic treatment other than digitalis. (Level of evidence: C)
	2.	Congenital third-degree AV block beyond the first day of life with an average heart rate <50 bpm or pauses in the ventricular rate that are two or three times the basic cycle length. (Level of evidence: B)
	3.	Long QT syndrome with 2:1 AV or third-degree AV block. (Level of evidence: B)
	4.	Asymptomatic sinus bradycardia in the child with complex congenital heart disease with resting heart rate >35 bpm or pauses in ventricular rate >3 seconds. (Level of evidence: C)
Class IIb
	1.	Transient postoperative third-degree AV block that reverts to sinus rhythm with residual bifascicular block. (Level of evidence: C)
	2.	Congenital third-degree AV block in the asymptomatic neonate, child, or adolescent with an acceptable rate, narrow QRS complex, and normal ventricular function. (Level of evidence: B)
	3.	Asymptomatic sinus bradycardia in the adolescent with congenital heart disease with resting heart rate <35 bpm or pauses in ventricular rate >3 seconds. (Level of evidence: C)
Class III
	1.	Transient postoperative AV block with return of normal AV conduction within 7 days. (Level of evidence: B)
	2.	Asymptomatic postoperative bifascicular block with or without first-degree AV block. (Level of evidence: C)
	3.	Asymptomatic type I second-degree AV block. (Level of evidence: C)
	4.	Asymptomatic sinus bradycardia in the adolescent with longest RR interval <3 seconds and minimum heart rate >40 bpm. (Level of evidence: C)

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Class I
	1.	Class I indications for sinus node dysfunction or AV block as previously described. (Level of evidence: C)
Class IIa
	None
Class IIb
	1.	Medically refractory, symptomatic hypertrophic cardiomyopathy with significant resting or provoked LV outflow obstruction. (Level of evidence: C)
Class III
	1.	Patients who are asymptomatic or medically controlled.
	2.	Symptomatic patients without evidence of LV outflow obstruction.

Class I
	1.	Class I indications for sinus node dysfunction or AV block as previously described. (Level of evidence: C)
Class IIa
	None
Class IIb
	1.	Symptomatic, drug-refractory dilated cardiomyopathy with prolonged PR interval when acute hemodynamic studies have demonstrated hemodynamic benefit of pacing. (Level of evidence: C)
Class III
	1.	Asymptomatic dilated cardiomyopathy.
	2.	Symptomatic dilated cardiomyopathy when patients are rendered asymptomatic by drug therapy..
	3.	Symptomatic ischemic cardiomyopathy.

Class I
	1.	Symptomatic bradyarrhythmias/chronotropic incompetence not expected to resolve and other Class I indications for permanent pacing. (Level of evidence: C)
Class IIa
	None
Class IIb
	1.	Symptomatic bradyarrhythmias/chronotropic incompetence that, although transient, may persist for now and require intervention. (Level of evidence: C)
Class III
	1.	Asymptomatic bradyarrhythmias after cardiac transplantation.

JACC Vol. 31, No. 5
April 1998: 1175-1209

ACC/AHA PRACTICE GUIDELINES