p.3 抽出テキスト

Kusumoto et al 2018 Bradycardia Clinical Practice Guidelines

August 20, 2019 Circulation. 2019;140:e382–e482. DOI: 10.1161/CIR.0000000000000628 e384

CLINICAL STATEMENTS AND GUIDELINES 8.1.2.	Postoperative Bradycardia and Conduction Disorders After Cardiac Surgery . . . . . . . . . . . . . . . . . . . . . . . . . e437 8.2.	 Bradycardia Management for Adult Congenital Heart Disease . . . . . . . . . . . . . . . . . e444 8.3.	 Management of Bradycardia in Patients With an Acute MI . . . . . . . . . . . . . . . . . . . . . . . e446 8.4.	 Neurologic Disorders . . . . . . . . . . . . . . . . . . . . e447 8.4.1.	Epilepsy . . . . . . . . . . . . . . . . . . . . . . . . . e447 9.  Evaluation of the Risks for Ventricular Arrhythmias in Patients Who Require Permanent Pacing �������������������������������������������������e448 10.  Cost and Value Considerations . . . . . . . . . . . . . . . . e448 11.  Shared Decision-Making . . . . . . . . . . . . . . . . . . . . . e449 12.  Quality of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . e450 13.  Discontinuation of Pacemaker Therapy . . . . . . . . . . e450 14.  End-of-Life Considerations . . . . . . . . . . . . . . . . . . . e450 15.  Knowledge Gaps and Future Research . . . . . . . . . . e451 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e452 Appendix 1  Author Relationships With Industry

and Other Entities (Relevant)�������������������e479 Appendix 2  Abbreviated Reviewer Relationships

With Industry and Other Entities �������������e481

TOP 10 TAKE-HOME MESSAGES FOR THE MANAGEMENT OF BRADYCARDIA AND CARDIAC CONDUCTION DELAY

1.	 Sinus node dysfunction is most often related to age-dependent progressive fibrosis of the sinus nodal tissue and surrounding atrial myocardium leading to abnormalities of sinus node and atrial impulse formation and propagation and will therefore result in various bradycardic or pauserelated syndromes. 2.	 Both sleep disorders of breathing and nocturnal bradycardias are relatively common, and treatment of sleep apnea not only reduces the frequency of these arrhythmias but also may offer cardiovascular benefits. The presence of nocturnal bradycardias should prompt consideration for screening for sleep apnea, beginning with solicitation of suspicious symptoms. However, nocturnal bradycardia is not in itself an indication for permanent pacing. 3.	 The presence of left bundle branch block on electrocardiogram markedly increases the likelihood of underlying structural heart disease and of diagnosing left ventricular systolic dysfunction. Echocardiography is usually the most appropriate initial screening test for structural heart disease, including left ventricular systolic dysfunction. 4.	 In sinus node dysfunction, there is no established minimum heart rate or pause duration where permanent pacing is recommended. Establishing temporal correlation between symptoms and bradycardia is important when determining whether permanent pacing is needed. 5.	 In patients with acquired second-degree Mobitz type II atrioventricular block, high-grade atrioventricular block, or third-degree atrioventricular block not caused by reversible or physiologic causes, permanent pacing is recommended regardless of symptoms. For all other types of atrioventricular block, in the absence of conditions associated with progressive atrioventricular conduction abnormalities, permanent pacing should generally be considered only in the presence of symptoms that correlate with atrioventricular block. 6.	 In patients with a left ventricular ejection fraction between 36% to 50% and atrioventricular block, who have an indication for permanent pacing and are expected to require ventricular pacing >40% of the time, techniques that provide more physiologic ventricular activation (eg, cardiac resynchronization therapy, His bundle pacing) are preferred to right ventricular pacing to prevent heart failure. 7.	 Because conduction system abnormalities are common after transcatheter aortic valve replacement, recommendations on postprocedure surveillance and pacemaker implantation are made in this guideline. 8.	 In patients with bradycardia who have indications for pacemaker implantation, shared decisionmaking and patient-centered care are endorsed and emphasized in this guideline. Treatment decisions are based on the best available evidence and on the patient’s goals of care and preferences. 9.	 Using the principles of shared decision-making and informed consent/refusal, patients with decision-making capacity or his/her legally defined surrogate has the right to refuse or request withdrawal of pacemaker therapy, even if the patient is pacemaker dependent, which should be considered palliative, end-of-life care, and not physician-assisted suicide. However, any decision is complex, should involve all stakeholders, and will always be patient specific. 10.	 Identifying patient populations that will benefit the most from emerging pacing technologies (eg, His bundle pacing, transcatheter leadless pacing systems) will require further investigation as these modalities are incorporated into clinical practice.

PREAMBLE

Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health.

Downloaded from http://ahajournals.org by on October 7, 2026