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)

 Gabriel Gregoratos, Melvin D. Cheitlin, Alicia Conill, Andrew E. Epstein, Christopher Fellows, T. Bruce Ferguson, Roger A. Freedman, Mark A. Hlatky, Gerald V. Naccarelli, Sanjeev Saksena, Robert C. Schlant, Michael J. Silka
Circulation. 1998;97:1325-1335  –  Originally published April 7, 1998

Class I

1. Third-degree AV block at any anatomic level associated with any one of the following conditions:

  1. Bradycardia with symptoms presumed to be due to AV block. (Level of evidence: C)
  2. Arrhythmias and other medical conditions that require drugs that result in symptomatic bradycardia. (Level of evidence: C)
  3. 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)
  4. 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.
  5. Postoperative AV block that is not expected to resolve. (Level of evidence: C)
  6. Neuromuscular diseases with AV block such as myotonic muscular dystrophy, Kearns-Sayre syndrome, Erb’s dystrophy (limb-girdle), and peroneal muscular atrophy. (Level of evidence: B)
  7. 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)

    1. Asymptomatic type II second-degree AV block. (Level of evidence: B)

    2. Asymptomatic type I second-degree AV block at intra- or infra-His levels found incidentally at electrophysiological study for other indications. (Level of evidence: B)

    3. 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) (See “Pacing for Chronic Bifascicular and Trifascicular Block.”)

  • 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 (eg, drug toxicity, Lyme disease). (Level of evidence: B)

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)

Class I

  1. Persistent second-degree AV block in the His-Purkinje system with bilateral bundle branch block 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) infranodal AV block and associated bundle branch block. If the site of block is uncertain, an electrophysiological 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)

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.

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.

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.

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.