ESC 2021 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy
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| 頁 | クラス | レベル | 推奨文 | 表 |
|---|---|---|---|---|
| p.9 | I | A | cardia or conduction system disease Monitoring In patients with infrequent (less than once a month) unexplained syncope or other symp- toms suspected to be caused by bradycardia, in whom a comprehensive evaluation did not demonstrate a cause, long-term ambulatory monitor- ing with an ILR is recommended. | Table 4 New recommendations in 2021 |
| p.9 | I | C | Ambulatory electrocardiographic monitoring is recommended in the evaluation of patients with suspected bradycardia to correlate rhythm dis- turbances with symptoms. Carotid massage | Table 4 New recommendations in 2021 |
| p.9 | I | B | Once carotid stenosis is ruled outc, carotid sinus massage is recommended in patients with syn- cope of unknown origin compatible with a reflex mechanism or with symptoms related to pressure/manipulation of the carotid sinus area. | Table 4 New recommendations in 2021 |
| p.9 | IIa | B | Tilt test Tilt testing should be considered in patients with suspected recurrent reflex syncope. Exercise test | Table 4 New recommendations in 2021 |
| p.9 | I | C | Exercise testing is recommended in patients who experience symptoms suspicious of brady- cardia during or immediately after exertion. | Table 4 New recommendations in 2021 |
| p.9 | IIa | B | In patients with suspected chronotropic incom- petence, exercise testing should be considered to confirm the diagnosis. | Table 4 New recommendations in 2021 |
| p.9 | IIb | C | In patients with intra-ventricular conduction disease or AVB of unknown level, exercise testing may be considered to expose infranodal block. Imaging | Table 4 New recommendations in 2021 |
| p.9 | I | C | Cardiac imaging is recommended in patients with suspected or documented symptomatic bradycardia to evaluate the presence of struc- tural heart disease, to determine left ventricular systolic function, and to diagnose potential causes of conduction disturbances. | Table 4 New recommendations in 2021 |
| p.9 | IIa | C | Multimodality imaging (CMR, CT, PET) should be considered for myocardial tissue character- ization in the diagnosis of specific pathologies associated with conduction abnormalities needing pacemaker implantation, particularly in patients younger than 60 years. | Table 4 New recommendations in 2021 |
| p.9 | I | C | cific laboratory tests are recommended in patients with clinical suspicion for potential causes of bradycardia (e.g. thyroid function tests, Lyme titre, digitalis level, potassium, calcium, and pH) to diagnose and treat these conditions. | Table 4 New recommendations in 2021 |
| p.9 | I | C | Sleep evaluation Screening for SAS is recommended in patients with symptoms of SAS and in the presence of severe bradycardia or advanced AVB during sleep. Electrophysiological study | Table 4 New recommendations in 2021 |
| p.9 | IIa | B | In patients with syncope and bifascicular block, EPS should be considered when syncope remains unexplained after non-invasive evalua- tion or when an immediate decision about pacing is needed due to severity, unless empirical pacemaker implantation is preferred (especially | Table 4 New recommendations in 2021 |
| p.9 | IIb | B | in elderly and frail patients). In patients with syncope and sinus bradycardia, EPS may be considered when non-invasive tests have failed to show a correlation between syn- cope and bradycardia. | Table 4 New recommendations in 2021 |
| p.9 | IIa | C | Genetics Genetic testing should be considered in patients with early onset (age <50 years) of progressive cardiac conduction disease. | Table 4 New recommendations in 2021 |
| p.9 | IIa | C | Genetic testing should be considered in family members following the identification of a patho- genic genetic variant that explains the clinical phenotype of cardiac conduction disease in an index case. | Table 4 New recommendations in 2021 |
| p.9 | I | B | Pacing is indicated in symptomatic patients with the bradycardia-tachycardia form of SND to cor- rect bradyarrhythmias and enable pharmacologi- cal treatment, unless ablation of the tachyarrhythmia is preferred. | Table 4 New recommendations in 2021 |
| p.9 | I | C | Pacing is indicated in patients with atrial arrhyth- mia (mainly AF) and permanent or paroxysmal third- or high-degree AVB irrespective of symptoms. | Table 4 New recommendations in 2021 |
| p.9 | I | A | In patients with SND and DDD PM, minimiza- tion of unnecessary ventricular pacing through programming is recommended. Dual chamber cardiac pacing is indicated to | Table 4 New recommendations in 2021 |
| p.9 | I | A | reduce recurrent syncope in patients aged >40 years with severe, unpredictable, recurrent syncope who have: • spontaneous documented symptomatic asys- Continued tolic pause/s >3 s or asymptomatic pause/s >6 s due to sinus arrest or AVB; or • cardioinhibitory carotid sinus syndrome; or • asystolic syncope during tilt testing. | Table 4 New recommendations in 2021 |
| p.10 | IIa | C | In patients with recurrent unexplained falls, the same assessment as for unexplained syncope should be considered. | |
| p.10 | IIa | C | AF ablation should be considered as a strategy to avoid pacemaker implantation in patients with AF-related bradycardia or symptomatic preautomaticity pauses, after AF conversion, taking into account the clinical situation. | |
| p.10 | IIb | B | In patients with the bradycardia-tachycardia var- iant of SND, programming of atrial ATP may be considered. | |
| p.10 | IIb | B | Dual-chamber cardiac pacing may be considered to reduce syncope recurrences in patients with the clinical features of adenosine-sensitive syncope. | |
| p.10 | I | A | Cardiac resynchronization therapy In patients who are candidates for an ICD and who have CRT indication, implantation of a CRT-D is recommended. | |
| p.10 | IIa | B | In patients who are candidates for CRT, implan- tation of a CRT-D should be considered after individual risk assessment and using shared deci- sion-making. | |
| p.10 | IIa | C | In patients with symptomatic AF and an uncontrolled heart rate who are candidates for AVJ ablation (irrespective of QRS duration), CRT rather than standard RV pacing should be considered in patients with HFmrEF. | |
| p.10 | IIa | B | In patients with symptomatic AF and an uncon- trolled heart rate who are candidates for AVJ ablation (irrespective of QRS duration), RV pacing should be considered in patients with HFpEF. | |
| p.10 | IIb | B | In patients with symptomatic AF and an uncon- trolled heart rate who are candidates for AVJ ablation (irrespective of QRS duration), CRT may be considered in patients with HFpEF. Alternate site pacing | |
| p.10 | I | C | His bundle pacing In patients treated with HBP, device programming tailored to specific requirements of His bundle pacing is recommended. | |
| p.10 | IIa | B | In CRT candidates in whom coronary sinus lead implantation is unsuccessful, HBP should be con- sidered as a treatment option along with other techniques such as surgical epicardial lead. | |
| p.10 | IIa | C | In patients treated with HBP, implantation of a right ventricular lead used as “backup” for pacing should be considered in specific situations (e.g. pacemaker-dependency, high-grade AVB, infranodal block, high pacing threshold, planned AVJ ablation), or for sensing in case of issues with detection (e.g. risk of ventricular undersensing or oversensing of atrial/His potentials). | |
| p.10 | IIb | C | HBP with a ventricular backup lead may be con- sidered in patients in whom a “pace-and-ablate” strategy for rapidly conducted supraventricular arrhythmia is indicated, particularly when intrin- sic QRS is narrow. | |
| p.10 | IIb | C | HBP may be considered as an alternative to right ventricular pacing in patients with AVB and LVEF >40%, who are anticipated to have >20% ven- tricular pacing. Leadless pacing | |
| p.10 | IIa | B | Leadless pacemakers should be considered as an alternative to transvenous pacemakers when no upper extremity venous access exists or when risk of device pocket infection is particularly high, such as previous infection and patients on haemodialysis. | |
| p.10 | IIb | C | Leadless pacemakers may be considered as an alternative to standard single lead ventricular pacing, taking into consideration life expectancy and using shared decision-making. Indications for pacing in specific conditions | |
| p.10 | I | C | Pacing in acute myocardial infarction Implantation of a permanent pacemaker is indi- cated with the same recommendations as in a general population (section 5.2) when AVB does not resolve within a waiting period of at least 5 days after MI. | |
| p.10 | IIb | C | ............................................................................................................................................................................ In selected patients with AVB in context of anterior wall MI and acute HF, early device implanta- tion (CRT-D/CRT-P) may be considered. Pacing in cardiac surgery | |
| p.10 | I | C | 1) High-degree or complete AVB after cardiac surgery. A period of clinical observation for at least 5 days is indicated in order to assess whether the rhythm disturbance is transient and resolves. However, in the case of complete AVB with low or no escape rhythm when resolution is unlikely, this observation period can be shortened. | |
| p.10 | IIa | C | SND after cardiac surgery and heart transplanta- tion. Before permanent pacemaker implantation, a period of observation for up to 6 weeks should be considered. | |
| p.10 | IIa | C | Chronotropic incompetence after heart trans- plantation. Cardiac pacing should be considered for chronotropic incompetence persisting more than 6 weeks after heart transplantation to improve quality of life. Continued | |
| p.11 | IIa | C | Surgery for valvular endocarditis and intraopera- tive complete AVB. Immediate epicardial pace- maker implantation should be considered in patients with surgery for valvular endocarditis and complete AVB if one of the following predic- tors of persistence is present: preoperative conduction abnormality, Staphylococcus aureus infection, intracardiac abscess, tricuspid valve involvement, or previous valvular surgery. | |
| p.11 | IIa | C | Patients requiring pacing at the time of tricuspid valve surgery. Transvalvular leads should be avoided and epicardial ventricular leads used. During tricuspid valve surgery, removal of pre- existing transvalvular leads should be considered and preferred over sewing-in the lead between the annulus and a bio-prosthesis or annuloplasty ring. In the case of an isolated tricuspid annulo- plasty based on an individual risk-benefit analysis, a pre-existing right ventricular lead may be left in | |
| p.11 | IIa | C | place without jailing it between ring and annulus. Patients requiring pacing after biological tricuspid valve replacement/tricuspid valve ring repair. When ventricular pacing is indicated, transve- nous implantation of a coronary sinus lead or minimally invasive placement of an epicardial ventricular lead should be considered and pre- ferred over a transvenous transvalvular | |
| p.11 | III | C | approach. Patients requiring pacing after mechanical tricus- pid valve replacement. Implantation of a trans- valvular right ventricular lead should be avoided. | |
| p.11 | I | B | Pacing in transcatheter aortic valve implantation Permanent pacing is recommended in patients with complete or high-degree AVB that persists for 24 - 48 h after TAVI. | |
| p.11 | I | C | Permanent pacing is recommended in patients with new onset alternating BBB after TAVI. Earlye permanent pacing should be considered in | |
| p.11 | IIa | B | patients with pre-existing RBBB who develop any further conduction disturbance during or after TAVI.f | |
| p.11 | IIa | C | Ambulatory ECG monitoringg or an electro- physiology studyh should be considered for patients with new LBBB with QRS >150 ms or PR >240 ms with no further prolongation during >48 h after TAVI. | |
| p.11 | IIb | C | Ambulatory ECG monitoringg or electrophysiol- ogy studyh may be considered for TAVI patients with pre-existing conduction abnormality who develop further prolongation of QRS or PR >20 ms. | |
| p.11 | III | C | Prophylactic permanent pacemaker implantation is not indicated before TAVI in patients with RBBB and no indication for permanent pacing. Various syndromes | |
| p.11 | I | C | In patients with neuromuscular diseases such as myotonic dystrophy type 1 and any second- or third-degree AVB or HV >_70 ms, with or with- out symptoms, permanent pacing is indicated.i | |
| p.11 | IIa | C | In patients with LMNA gene mutations, including Emery-Dreifuss and limb girdle muscular dystro- phies who fulfil conventional criteria for pace- maker implantation or who have prolonged PR with LBBB, ICD implantation with pacing capabil- ities should be considered if at least 1-year sur- | |
| p.11 | IIa | C | vival is expected. In patients with Kearns-Sayre syndrome who have PR prolongation, any degree of AVB, bun- dle branch block, or fascicular block, permanent pacing should be considered. | |
| p.11 | IIb | C | In patients with neuromuscular disease such as myotonic dystrophy type 1 with PR >_240 ms or QRS duration >_120 ms, permanent pacemaker implantation may be considered.i | |
| p.11 | IIb | C | In patients with Kearns-Sayre Syndrome without cardiac conduction disorder, permanent pacing may be considered prophylactically. Sarcoidosis | |
| p.11 | IIa | C | In patients with cardiac sarcoidosis who have permanent or transient AVB, implantation of a device capable of cardiac pacing should be considered.i | |
| p.11 | IIa | C | In patients with sarcoidosis and indication for permanent pacing who have LVEF <50%, implantation of a CRT-D should be considered. | |
| p.11 | I | A | tive management Administration of preoperative antibiotic prophylaxis within 1 h of skin incision is recom- mended to reduce risk of CIED infection. | |
| p.11 | IIa | B | Chlorhexidine alcohol instead of povidoneiodine alcohol should be considered for skin Continued antisepsis. | |
| p.12 | IIa | B | For venous access, the cephalic or axillary vein should be considered as first choice. | |
| p.12 | IIa | C | For implantation of coronary sinus leads, quadri- polar leads should be considered as first choice. | |
| p.12 | IIa | C | To confirm target ventricular lead position, use of multiple fluoroscopic views should be considered. | |
| p.12 | IIa | C | Rinsing the device pocket with normal saline solution before wound closure should be considered. | |
| p.12 | IIb | B | In patients undergoing a reintervention CIED procedure, the use of an antibiotic-eluting enve- lope may be considered. | |
| p.12 | IIb | C | Pacing of the mid-ventricular septum may be considered in patients with a high risk of perfora- tion (elderly, previous perforation). | |
| p.12 | IIb | C | In pacemaker implantations in patients with pos- sible pocket issues such as increased risk of erosion due to low body mass index, Twiddler’s syndrome or aesthetic reasons, a submuscular | |
| p.12 | III | A | device pocket may be considered. Heparin-bridging of anticoagulated patients is not recommended. | |
| p.12 | III | B | Permanent pacemaker implantation is not rec- ommended in patients with fever. Pacemaker implantation should be delayed until the patient has been afebrile for at least 24 h. Management considerations | |
| p.12 | I | A | Remote monitoring Remote device management is recommended to reduce number of in-office follow-up in patients with pacemakers who have difficulties to attend in-office visits (e.g. due to reduced mobility or other commitments or according to patient preference). | |
| p.12 | I | C | Remote monitoring is recommended in case of a device component that has been recalled or is on advisory, to enable early detection of action- able events in patients, particularly those who are at increased risk (e.g. in case of pacemaker- dependency). | |
| p.12 | IIa | A | In-office routine follow-up of single- and dual- chamber pacemakers may be spaced by up to 24 months in patients on remote device management. | |
| p.12 | I | C | Temporary pacing Temporary transvenous pacing is recommended in cases of haemodynamic-compromising bradyarrhythmia refractory to intravenous chrono- tropic drugs. | |
| p.12 | IIa | C | Transcutaneous pacing should be considered in cases of haemodynamic compromising bradyar- rhythmia when temporary transvenous pacing is not possible or available. | |
| p.12 | IIa | C | Temporary transvenous pacing should be considered when immediate pacing is indicated and pacing indications are expected to be reversible, such as in the context of myocardial ischaemia, myocarditis, electrolyte disturbances, toxic exposure, or after cardiac surgery. | |
| p.12 | IIa | C | ..................................................................................................................................... Temporary transvenous pacing should be considered as a bridge to permanent pacemaker implantation, when this procedure is not imme- diately available or possible due to concomitant infection. | |
| p.12 | IIa | C | For long-term temporary transvenous pacing, an active fixation lead inserted through the skin and connected to an external pacemaker should be considered. Miscellaneous | |
| p.12 | I | C | When pacing is no longer indicated, a decision on the management strategy should be based on an individual risk-benefit analysis in a shared decision-making process together with the | |
| p.12 | IIb | C | patient. MRI may be considered in pacemaker patients with abandoned transvenous leads if no alterna- tive imaging modality is available. Continued | |
| p.13 | I | C | Patient-centred care In patients considered for pacemaker or CRT, the decision should be based on the best available evidence with consideration of individual risk-benefits of each option, the patients preferences, and goals of care, and it is recommended to follow an integrated care approach and use the principles of patient- centred care and shared decision making in the consultation. | |
| p.18 | I | B | 4.3 Non-invasive evaluation Once carotid stenosis is ruled out,c CSM is rec- ommended in patients with syncope of unknown origin compatible with a reflex mechanism or with symptoms related to pressure/manipulation of the carotid sinus area.6870 Continued | |
| p.19 | I | C | <1 per month ILR ECG = electrocardiogram; ILR = implantable loop recorder. Adapted from Brignole et al.33 Ambulatory ECG monitoring is recommended in the evaluation of patients with suspected bradycardia to correlate rhythm disturbances with symptoms.73 ECG = electrocardiogram. aClass of recommendation. bLevel of evidence. | |
| p.19 | I | C | Recommendations for exercise testing ESC 2021 Exercise testing is recommended in patients who experience symptoms suspicious of brady- cardia during or immediately after exertion.62,7480 | |
| p.19 | IIa | B | In patients with suspected chronotropic incom- petence, exercise testing should be considered to confirm the diagnosis.74,75 | |
| p.19 | IIb | C | .......................................................................................... In patients with intraventricular conduction disease or AVB of unknown level, exercise testing may be considered to expose infranodal block.76,77,79 ESC 2021 AVB = atrioventricular block. aClass of recommendation. bLevel of evidence. | |
| p.20 | I | C | Cardiac imaging is recommended in patients with suspected or documented symptomatic bradycardia to evaluate the presence of struc- tural heart disease, to determine LV systolic function, and to diagnose potential causes of conduction disturbances. | |
| p.20 | IIa | C | Multimodality imaging (CMR, CT, or PET) should be considered for myocardial tissue characterization in the diagnosis of specific pathologies associated with conduction abnormalities need- ing pacemaker implantation, particularly in patients younger than 60 years.8386,88 | |
| p.20 | I | C | ................................................... Recommendations for laboratory tests In addition to pre-implantation laboratory tests,c specific laboratory tests are recommended in patients with clinical suspicion for potential underlying causes of reversible bradycardia (e.g. thyroid function tests, Lyme titre, digitalis level, potassium, calcium, and pH) to diagnose and treat these conditions.9094 | |
| p.21 | IIa | B | Tilt testing should be considered in patients with suspected recurrent reflex syncope.62 | |
| p.21 | IIa | C | Recommendations for genetic testing Genetic testing should be considered in patients with early onset (age <50 years) of progressive cardiac conduction disease.c 65,97 | |
| p.21 | IIa | C | Genetic testing should be considered in family members following the identification of a patho- genic genetic variant that explains the clinical phenotype of cardiac conduction disease in an index case.65 | |
| p.21 | I | C | Recommendation for sleep evaluation Screening for SAS is recommended in patients with symptoms of SAS and in the presence of severe bradycardia or advanced AVB during sleep.101106 AVB = atrioventricular block; SAS = sleep apnoea syndrome. aClass of recommendation. bLevel of evidence. | |
| p.21 | I | A | In patients with infrequent (less than once a month) unexplained syncope or other symp- toms suspected to be caused by bradycardia, in whom a comprehensive evaluation did not demonstrate a cause, long-term ambulat ory monitoring with an ILR is ESC 2021 recommended.108112 ILR = implantable loop recorder. aClass of recommendation. bLevel of evidence. | |
| p.23 | IIa | B | In patients with syncope and bifascicular block, EPS should be considered when syncope remains unexplained after non-invasive evalua- tion or when an immediate decision about pacing is needed due to severity, unless empirical pacemaker implantation is preferred (especially | |
| p.23 | IIb | B | in elderly and frail patients).115121 In patients with syncope and sinus bradycardia, EPS may be considered when non-invasive tests have failed to show a correlation between syn- cope and bradycardia.113,114 EPS = electrophysiology study. aClass of recommendation. bLevel of evidence. | |
| p.26 | I | A | In patients with SND and a DDD pacemaker, minimization of unnecessary ventricular pacing through programming is recommended.144,151,159,164,166169 | |
| p.26 | I | B | Pacing is indicated in SND when symptoms can clearly be attributed to bradyarrhythmias.14,128131 | |
| p.26 | I | B | Pacing is indicated in symptomatic patients with the bradycardiatachycardia form of SND in order to correct bradyarrhythmias and enable pharmacological treatment, unless ablation of the tachyarrhythmia is preferred.17,20,21,136138,170,171 | |
| p.26 | IIa | B | In patients who present chronotropic incompetence and have clear symptoms during exercise, DDD with rate-responsive pacing should be considered.172,173 | |
| p.26 | IIa | C | AF ablation should be considered as a strategy to avoid pacemaker implantation in patients with AF-related bradycardia or symptomatic pre- automaticity pauses, after AF conversion, taking into account the clinical situation.136139,174 | |
| p.26 | IIb | B | In patients with the bradycardiatachycardia variant of SND, programming of atrial ATP may be considered.164,165 | |
| p.26 | IIb | C | In patients with syncope, cardiac pacing may be considered to reduce recurrent syncope when asymptomatic pause(s) >6 s due to sinus arrest is documented.133,134 | |
| p.26 | IIb | C | Pacing may be considered in SND when symp- toms are likely to be due to bradyarrhythmias, when the evidence is not conclusive. | |
| p.26 | III | C | Pacing is not recommended in patients with bra- dyarrhythmias related to SND that are asympto- matic or due to transient causes that can be corrected and prevented.33 | |
| p.27 | I | C | Pacing is indicated in patients in SR with perma- nent or paroxysmal third- or second-degree type 2, infranodal 2:1, or high-degree AVB, irrespective of symptoms.c 912 | |
| p.27 | I | C | Pacing is indicated in patients with atrial arrhyth- mia (mainly AF) and permanent or paroxysmal third- or high-degree AVB irrespective of symptoms. | |
| p.27 | I | C | In patients with permanent AF in need of a pace- maker, ventricular pacing with rate response function is recommended.201204 | |
| p.27 | IIa | C | ................................................................................................................... Pacing should be considered in patients with sec- ond-degree type 1 AVB that causes symptoms or is found to be located at intra- or infra-His levels at EPS.177180 | |
| p.27 | IIa | A | In patients with AVB, DDD should be preferred over single-chamber ventricular pacing to avoid pacemaker syndrome and to improve quality of life.20,140,181,182 | |
| p.27 | IIa | C | Permanent pacemaker implantation should be considered for patients with persistent symptoms similar to those of pacemaker syndrome and clearly attributable to first-degree AVB (PR >0.3 s).205207 | |
| p.27 | III | C | Pacing is not recommended in patients with AVB due to transient causes that can be corrected and prevented. | |
| p.29 | III | B | BBB or bifascicular block.115,121,215 | |
| p.29 | I | B | In patients with unexplained syncope and bifas- cicular block, a pacemaker is indicated in the presence of either a baseline HV of >_70 ms, sec- ond- or third-degree intra- or infra-Hisian block during incremental atrial pacing, or an abnormal response to pharmacological challenge.119,120 | |
| p.29 | I | C | .......................................................................... Pacing is indicated in patients with alternating BBB with or without symptoms. | |
| p.29 | IIb | B | Pacing may be considered in selected patients with unexplained syncope and bifascicular block without EPS (elderly, frail patients, high-risk and/ or recurrent syncope).213 Pacing is not recommended for asymptomatic | |
| p.32 | III | B | a documented cardioinhibitory reflex.231,232 | |
| p.32 | I | A | Dual-chamber cardiac pacing is indicated to reduce recurrent syncope in patients aged >40 years, with severe, unpredictable, recurrent syn- cope who have: • spontaneous documented symptomatic asys- tolic pause(s) >3 s or asymptomatic pause(s) >6 s due to sinus arrest or AVB; or • cardioinhibitory carotid sinus syndrome; or • asystolic syncope during tilt | |
| p.32 | IIb | B | testing.62,219,220,226,228,229 Dual-chamber cardiac pacing may be considered to reduce syncope recurrences in patients with the clinical features of adenosine-sensitive syncope.230 Cardiac pacing is not indicated in the absence of AVB = atrioventricular block. aClass of recommendation. bLevel of evidence. | |
| p.32 | IIa | C | In patients with recurrent unexplained falls, the same assessment as for unexplained syncope should be considered.62 | |
| p.32 | III | B | Pacing is not recommended in patients with unexplained falls in the absence of any other documented indication.236 | |
| p.32 | III | C | ................................................................................................................... Pacing is not recommended in patients with unexplained syncope without evidence of SND or conduction disturbance.234,235 SND = sinus node dysfunction. aClass of recommendation. bLevel of evidence. ESC 2021 | |
| p.34 | I | A | LBBB QRS morphology CRT is recommended for symptomatic patients with HF in SR with LVEF <_35%, QRS duration >_150 ms, and LBBB QRS morphology despite OMT, in order to improve symptoms and reduce morbidity and mortality.37,39,40,254266,283,284 | |
| p.34 | IIa | B | CRT should be considered for symptomatic patients with HF in SR with LVEF <_35%, QRS duration 130149 ms, and LBBB QRS morphology despite OMT, in order to improve symp- toms and reduce morbidity and mortality.37,39,40,254266,283,284 | |
| p.34 | IIa | B | ................................................................................................................ Non-LBBB QRS morphology CRT should be considered for symptomatic patients with HF in SR with LVEF <_35%, QRS duration >_150 ms, and non-LBBB QRS morphology despite OMT, in order to improve symp- toms and reduce morbidity.37,39,40,254266,283,284 | |
| p.34 | IIb | B | CRT may be considered for symptomatic patients with HF in SR with LVEF <_35%, QRS duration 130149 ms, and non-LBBB QRS mor- phology despite OMT, in order to improve symptoms and reduce morbidity.273278,281 | |
| p.34 | III | A | QRS duration CRT is not indicated in patients with HF and QRS duration <130 ms without an indication for RV pacing.264,282 | |
| p.37 | I | B | HFrEF.196,197,306,308 | |
| p.37 | IIa | B | with HFpEF.188,196,323 | |
| p.37 | IIa | C | for CRT: 1A) CRT should be considered for patients with HF and LVEF <_35% in NYHA class III or IV despite OMT if they are in AF and have intrinsic QRS >_130 ms, provided a strategy to ensure biventricular capture is in place, in order to improve symptoms and reduce morbidity and | |
| p.37 | IIa | B | mortality.302,306,307,322 1B) AVJ ablation should be added in the case of incomplete biventricular pacing (<9095%) due to conducted AF.297302 | |
| p.37 | IIa | C | 2A) CRT is recommended in patients with 2B) CRT rather than standard RV pacing should be considered in patients with HFmrEF. 2C) RV pacing should be considered in patients | |
| p.37 | IIb | C | 2D) CRT may be considered in patients with HFpEF. | |
| p.37 | IIa | B | ....................................................... ESC 2021 Patients who have received a conventional pace- maker or an ICD and who subsequently develop symptomatic HF with LVEF <_35% despite OMT, and who have a significantc proportion of RV pacing, should be considered for upgrade to CRT.37,148,185,190,324352 | |
| p.38 | I | A | CRT rather than RV pacing is recommended for patients with HFrEF (<40%) regardless of NYHA class who have an indication for ventricular pac- ing and high-degree AVB in order to reduce morbidity. This includes patients with AF.183,190,196,268,313,323,357359,361,362 | |
| p.39 | I | A | In patients who are candidates for an ICD and who have CRT indication, implantation of a CRT-D is recommended.260,369,370,381 | |
| p.39 | IIa | B | In patients who are candidates for CRT, implan- tation of a CRT-D should be considered after individual risk assessment and using shared deci- sion-making.382,383 | |
| p.43 | I | C | In patients treated with HBP, device program- ming tailored to specific requirements of HBP is recommended.430,431 | |
| p.43 | IIa | B | In CRT candidates in whom coronary sinus lead implantation is unsuccessful, HBP should be con- sidered as a treatment option along with other techniques such as surgical epicardial lead.318,424,440,443 | |
| p.43 | IIa | C | In patients treated with HBP, implantation of an RV lead used as ‘backup’ for pacing should be considered in specific situations (e.g. pacemaker dependency, high-grade AVB, infranodal block, high pacing threshold, planned AVJ ablation) or for sensing in the case of issues with detection (e.g. risk of ventricular undersensing or oversensing of atrial/His potentials).423,426,444 | |
| p.43 | IIb | C | HBP with a ventricular backup lead may be con- sidered in patients in whom a ‘pace-and-ablate’ strategy for rapidly conducted supraventricular arrhythmia is indicated, particularly when the intrinsic QRS is narrow.197,199,200,318 | |
| p.43 | IIb | C | ................................. HBP may be considered as an alternative to RV pacing in patients with AVB and LVEF >40%, who are anticipated to have >20% ventricular pacing.42,433 | |
| p.44 | III | B | revascularization or spontaneously.454456,458 | |
| p.44 | IIa | B | Leadless pacemakers should be considered as an alternative to transvenous pacemakers when no upper extremity venous access exists or when risk of device pocket infection is particularly high, such as previous infection and patients on haemodialysis.45,4750,450 | |
| p.44 | IIb | C | Leadless pacemakers may be considered as an alternative to standard single-lead ventricular pacing, taking into consideration life expectancy and using shared decision-making.45,4750 aClass of recommendation. bLevel of evidence. | |
| p.44 | I | C | ESC 2021 Implantation of a permanent pacemaker is indicated with the same recommendations as in a general population (section 5.2) when AVB does not resolve within a waiting period of at least 5 days after MI. | |
| p.44 | IIb | C | .......................................................................................... In selected patients with AVB in the context of anterior wall MI and acute HF, early device implantation (CRT-D/CRT-P) may be considered.471 Pacing is not recommended if AVB resolves after | |
| p.46 | I | C | 1) High-degree or complete AVB after cardiac surgery A period of clinical observation of at least 5 days is indicated to assess whether the rhythm disturbance is transient and resolves. However, in the case of complete AVB with low or no escape rhythm when resolution is unlikely, this observation period can be shortened.473,478 | |
| p.46 | IIa | C | 2) Surgery for valvular endocarditis and intraoperative complete AVB Immediate epicardial pacemaker implantation should be considered in patients with surgery for valvular endocarditis and complete AVB if one of the following predictors of persistence is present: pre-operative conduction abnormality, Staphylococcus aureus infection, intracardiac abscess, tricuspid valve involvement, or previous | |
| p.46 | IIa | C | valvular surgery.481 3) SND after cardiac surgery and heart transplantation Before permanent pacemaker implantation, a period of observation of up to 6 weeks should be considered.473 | |
| p.46 | IIa | C | 4) Chronotropic incompetence after heart transplantation Cardiac pacing should be considered for chronotropic incompetence persisting for >6 weeks after heart transplantation to improve quality of life.485 5) Patients requiring pacing at the time of tricuspid valve surgery | |
| p.46 | IIa | C | Transvalvular leads should be avoided and epi- cardial ventricular leads used. During tricuspid valve surgery, removal of pre-existing transvalv- ular leads should be considered and preferred over sewing in the lead between the annulus and a bioprosthesis or annuloplasty ring. In the case of an isolated tricuspid annuloplasty based on an individual riskbenefit analysis, a preexisting RV lead may be left in place without jail- | |
| p.46 | IIa | C | ing it between ring and annulus. 6) Patients requiring pacing after biological tricuspid valve replacement/tricuspid valve ring repair When ventricular pacing is indicated, transvenous implantation of a coronary sinus lead or minimally invasive placement of an epicardial ventricular lead should be considered and preferred over a transvenous transvalvular approach.487 | |
| p.46 | III | C | ........................... 7) Patients requiring pacing after mechan- ical tricuspid valve replacement Implantation of a transvalvular RV lead should be avoided. | |
| p.48 | I | B | Permanent pacing is recommended in patients with complete or high-degree AVB that persists for 24 - 48 h after TAVI.546 | |
| p.48 | I | C | Permanent pacing is recommended in patients with new-onset alternating BBB after TAVI.533,547 | |
| p.48 | IIa | B | Earlyc permanent pacing should be considered in patients with pre-existing RBBB who develop any further conduction disturbance during or after TAVI.d | |
| p.48 | IIa | C | Ambulatory ECG monitoringe or EPSf should be considered for patients with new LBBB with QRS >150 ms or PR >240 ms with no further prolongation during the >48 h after TAVI.536,537,548 | |
| p.48 | IIb | C | Ambulatory ECG monitoringe or EPSf may be considered for patients with a pre-existing con- duction abnormality who develop prolongation of QRS or PR >20 ms.g | |
| p.48 | III | C | Prophylactic permanent pacemaker implantation is not indicated before TAVI in patients with RBBB and no indication for permanent pacing. | |
| p.49 | I | C | In patients with congenital complete or high- degree AVB, pacing is recommended if one of the following risk factors is present: a. Symptoms b. Pauses >3 the cycle length of the ventricu- lar escape rhythm c. Broad QRS escape rhythm d. Prolonged QT interval e. Complex ventricular ectopy | |
| p.49 | IIb | C | f. Mean daytime heart rate <50 b.p.m. In patients with congenital complete or highdegree AVB, permanent pacing may be consid- ered even if no risk factors are present.566 | |
| p.49 | IIb | C | In patients with persistent post-operative bifas- cicular block associated with transient complete AVB, permanent pacing may be considered.572 | |
| p.49 | IIb | C | ....................................... In patients with complex CHD and asymptomatic bradycardia (awake resting heart rate <40 b.p.m. or pauses >3 s), permanent pacing may be considered on an individual basis. | |
| p.50 | IIb | B | AV sequential pacing with short AV delay may be considered in patients in SR who have other pacing or ICD indications if drug-refractory symptoms or baseline or provocable LV outflow tract gradients >_50 mmHg are present.576581,584 | |
| p.50 | IIb | C | AV sequential pacing with short AV delay may be considered in selected patients with drug- refractory symptoms, >_50 mmHg baseline or provocable LV outflow tract gradients, in SR, at high risk of developing AVB during septal ablation.585,586 | |
| p.50 | I | C | In patients with neuromuscular diseases such as myotonic dystrophy type 1 and any second- or third-degree AVB or HV >_70 ms, with or without symptoms, permanent pacing is indicated.c 599602 | |
| p.50 | IIb | C | ...................................................... In patients with neuromuscular disease such as myotonic dystrophy type 1 with PR >_240 ms or QRS duration >_120 ms, permanent pacemaker implantation may be considered.c 600,603,604 | |
| p.51 | IIa | C | In patients with LMNA gene mutations, including EmeryDreifuss and limb-girdle muscular dys- trophies who fulfil conventional criteria for pacemaker implantation or who have prolonged PR interval with LBBB, ICD implantation with pacing capabilities should be considered if at least 1year survival is expected.616 | |
| p.51 | IIa | C | In patients with KearnsSayre syndrome who have PR prolongation, any degree of AVB, BBB, or fascicular block, permanent pacing should be considered.c 621625 | |
| p.51 | IIb | C | In patients with KearnsSayre syndrome without cardiac conduction disorder, permanent pacing may be considered prophylactically.c 621625 | |
| p.52 | IIa | C | In patients with cardiac sarcoidosis who have permanent or transient AVB, implantation of a device capable of cardiac pacing should be considered.c 88,629,630 | |
| p.52 | IIa | C | In patients with sarcoidosis and an indication for permanent pacing who have LVEF <50%, implan- tation of a CRT-D should be considered.631,634 | |
| p.55 | IIa | B | should be considered as first choice.658,659 | |
| p.55 | III | A | Heparin bridging of anticoagulated patients is not recommended.650,689 | |
| p.55 | I | A | Administration of pre-operative antibiotic pro- phylaxis within 1 h of skin incision is recommended to reduce risk of CIED infection.641,643.686 | |
| p.55 | IIa | B | Chlorhexidinealcohol instead of povidoneiodinealcohol should be considered for skin antisepsis.647,648 For venous access, the cephalic or axillary vein | |
| p.55 | IIa | C | To confirm target ventricular lead position, use of multiple fluoroscopic views should be considered. | |
| p.55 | IIa | C | For implantation of coronary sinus leads, quadripolar leads should be considered as first choice.665,666,687 | |
| p.55 | IIa | C | Rinsing the device pocket with normal saline solution before wound closure should be considered.683,684 | |
| p.55 | IIb | B | In patients undergoing a reintervention CIED procedure, the use of an antibiotic-eluting envelope may be considered.685,688 | |
| p.55 | IIb | C | Pacing of the mid-ventricular septum may be considered in patients at high risk of perforation (e.g. elderly, previous perforation, low body mass index, women).420,674 | |
| p.55 | IIb | C | In pacemaker implantations in patients with pos- sible pocket issues such as increased risk of ero- sion due to low body mass index, Twiddler’s syndrome, or for aesthetic reasons, a submuscu- lar device pocket may be considered. | |
| p.55 | III | B | ..................................................... Permanent pacemaker implantation is not rec- ommended in patients with fever. Pacemaker implantation should be delayed until the patient has been afebrile for at least 24 h.638,639 CIED = cardiovascular implantable electronic device. aClass of recommendation. bLevel of evidence. | |
| p.59 | I | A | (Class I) In patients with MRI-conditional pacemaker sys- tems,c MRIs can be performed safely following the manufacturer’s instructions.745,753755 | |
| p.59 | IIa | B | In patients with non-MRI-conditional pacemaker systems, MRI should be considered if no alternative imaging mode is available and if no epicardial leads, abandoned or damaged leads, or lead adaptors/extenders are present.744,746 | |
| p.59 | IIb | C | MRI may be considered in pacemaker patients with abandoned transvenous leads if no alterna- tive imaging modality is available.748751 | |
| p.61 | I | C | Temporary transvenous pacing is recommended in cases of haemodynamic-compromising bra- dyarrhythmia refractory to intravenous chrono- tropic drugs.764,765 | |
| p.61 | IIa | C | Transcutaneous pacing should be considered in cases of haemodynamic-compromising bradyar- rhythmia when temporary transvenous pacing is not possible or available.783785 | |
| p.61 | IIa | C | Temporary transvenous pacing should be con- sidered when immediate pacing is indicated and pacing indications are expected to be reversible, such as in the context of myocardial ischaemia, myocarditis, electrolyte disturbances, toxic exposure, or after cardiac surgery.771773 | |
| p.61 | IIa | C | Temporary transvenous pacing should be con- sidered as a bridge to permanent pacemaker implantation when this procedure is not immediately available or possible due to concomitant infection.771773 | |
| p.61 | IIa | C | For long-term temporary transvenous pacing, an active fixation lead inserted through the skin and connected to an external pacemaker should be considered.641,776,777,779 aClass of recommendation. bLevel of evidence. | |
| p.62 | I | C | When pacing is no longer indicated, the decision on management strategy should be based on an individual riskbenefit analysis in a shared deci- sion-making process together with the patient. aClass of recommendation. bLevel of evidence. | |
| p.63 | I | A | Remote device management is recommended to reduce the number of in-office follow-ups in patients with pacemakers who have difficulties to attend in-office visits (e.g. due to reduced mobility or other commitments, or according to patient preference).805,806,809 | |
| p.63 | I | C | Remote monitoring is recommended in the case of a device component that has been recalled or is on advisory, to enable early detection of actionable events in patients, particularly those who are at increased risk (e.g. in the case of pacemaker dependency). | |
| p.63 | IIa | A | In-office routine follow-up of single- and dual- chamber pacemakers may be spaced by up to 24 months in patients on remote device management.805,806 | |
| p.63 | IIa | B | Remote device management of pacemakers should be considered in order to provide earlier detection of clinical problems (e.g. arrhythmias) or technical issues (e.g. lead failure or battery depletion).806,810 aClass of recommendation. bLevel of evidence. | |
| p.63 | I | C | ............................................................................................................ ESC 2021 In patients considered for pacemaker or CRT, the decision should be based on the best avail- able evidence with consideration of individual riskbenefits of each option, the patient’s pref- erences, and goals of care, and it is recom- mended to follow an integrated care approach and use the principles of patient-centred care and shared decision-making in the consultation.831836 CRT = cardiac resynchronization therapy. aClass of recommendation. bLevel of evidence. 13 Quality indicators | |
| p.68 | I | B | Pacing is indicated in SND when symptoms can clearly be attributed to bradyarrhythmias. | |
| p.68 | I | C | degree AVB, irrespective of symptoms.e | |
| p.68 | I | C | In patients with permanent AF in need of a pacemaker, ventricular pacing with rate response function is recommended. | |
| p.68 | III | C | Pacing is not recommended in patients with AVB due to transient causes that can be corrected and prevented. | |
| p.68 | I | C | Pacing is indicated in patients with alternating BBB with or without symptoms. | |
| p.68 | III | B | Pacing is not recommended for asymptomatic BBB or bifascicular block. | |
| p.68 | III | B | Cardiac pacing is not indicated in the absence of a documented cardioinhibitory reflex. | |
| p.68 | III | B | Pacing is not recommended in patients with unexplained falls in the absence of any other documented indication. | |
| p.68 | III | C | Pacing is not recommended in patients with unexplained syncope without evidence of SND or conduction disturbance. | |
| p.68 | III | A | CRT is not indicated in patients with HF and a QRS duration <130 ms without indication for RV pacing. | |
| p.68 | I | A | In patients who are candidates for an ICD, and who have CRT indication, implantation of a CRT-D is recommended. | |
| p.68 | III | B | Pacing is not recommended if AVB resolves after revascularization or spontaneously. | |
| p.69 | III | C | Patients requiring pacing after mechanical tricuspid valve replacement: implantation of a transvalvular RV lead should be avoided. | |
| p.69 | I | B | Permanent pacing is recommended in patients with complete or high-degree AVB that persists for 24 - 48 h after TAVI. | |
| p.69 | I | C | Permanent pacing is recommended in patients with new-onset alternating BBB after TAVI. | |
| p.69 | I | C | In patients with neuromuscular diseases such as myotonic dystrophy type 1 and any second- or third-degree AVB or HV >_70 ms, with or without symptoms, permanent pacing is indicated.f | |
| p.69 | I | A | Administration of pre-operative antibiotic prophylaxis within 1 h of skin incision is recommended to reduce the risk of CIED infection. | |
| p.69 | III | A | Heparin bridging of anticoagulated patients is not recommended. | |
| p.69 | I | A | In patients with MRI-conditional pacemaker systems,g MRI can be performed safely following the manufacturer’s instructions. |