p.30 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay

ACC-AHA 2018 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay 連続表示で読む PDF を別タブで
画像は 30 ページを描画したものです
p.30 抽出テキスト

Kusumoto et al 2018 Bradycardia Clinical Practice Guidelines

Circulation. 2019;140:e382–e482. DOI: 10.1161/CIR.0000000000000628 August 20, 2019 e411 CLINICAL STATEMENTS AND GUIDELINES

III: Harm C-LD 3.  In patients with SND with minimal and/or infrequent symptoms without hemodynamic compromise, temporary transcutaneous or transvenous pacing should not be performed.S5.3.3-4,S5.3.3-6,S5.3.3-7,

S5.3.3-12,S5.3.3-14–S5.3.3-16,S5.3.3-23

Synopsis

Indications for temporary transvenous pacing are similar to indications for permanent pacing.S5.3.3-24 The use of temporary transvenous pacing for SND is uncommon, because the risk of acute adverse cardiovascular events attributable to SND is low, and temporary pacing is associated with complications. Typically, temporary transvenous pacing is performed via a pacing wire placed in the RV from a central venous access site. Reported adverse event rates associated with temporary transvenous pacing range from 14% to 40%.S5.3.3-10,S5.3.3-25 Complications include venous thrombosis (18%–85% in the femoral setting when the femoral vein is used as the access), pulmonary emboli (50%–60% with femoral approach), life-threatening arrhythmias (usually related to instability or position in the RV), loss of capture (10%–37%), perforation, and death, but these associations may be confounded by use of temporary transvenous pacing in critically ill patients.S5.3.3-5,S5.3.3-15, S5.3.3-25–S5.3.3-27 Reported complications may be lower using balloon flotation electrode cathetersS5.3.3-5 or fluoroscopy. The risk of infectious complications in PPM placement is increased in patients who have a temporary pacing wire before permanent implant.S5.3.3-28,S5.3.3-29 Figure 5 provides an algorithm for choosing specific pacing strategy once temporary pacing is thought to be clinically necessary.

Recommendation-Specific Supportive Text

1.	 There are no RCTs or observational studies specific to the use of temporary transvenous pacing to treat SND, but several case seriesS5.3.3-4,S5.3.3-

6,S5.3.3-7,S5.3.3-10,S5.3.3-12,S5.3.3-14,S5.3.3-15,S5.3.3-17,S5.3.3-23 and 2 RCTsS5.3.3-3,S5.3.3-5,S5.3.3-27 include patients with SND. Overall, temporary transvenous pacing was effective, yet associated with complication rates that range from 14% to 40%.S5.3.3-10,S5.3.3-25 2.	 Although transcutaneous pacing has not shown a benefit in patients with cardiac arrest caused by asystole,S5.3.3-30 studies that included patients with SND without cardiac arrest have shown effective pacing with increases in heart rate and blood pressure, and tolerable patient tolerance.S5.3.3-1,S5.3.3-18–S5.3.3-20,S5.3.3-22 A systematic review of 3 unblinded RCTs, 3 case series, and 1 subgroup analysis showed a borderline improvement in survival to discharge in nonasystolic patients with symptomatic bradycardia.S5.3.3-21 Analgesic and/or anxiolytic agents should be considered in conscious patients, and effective capture assessed must be assessed by pulse or arterial waveform acquired by noninvasive or invasive means. Preparation for transcutaneous pacing (placing pads on a patient) may be considered for the patient who is at risk for developing bradycardia. This strategy has shown to be effective in the perioperative setting for rapid treatment of bradycardia.S5.3.3-31

3.	 Because temporary transvenous pacing is associated with a high risk of complications in older studies,S5.3.3-5,S5.3.3-10,S5.3.3-15,S5.3.3-25–S5.3.3-29 and although the risks are likely lower with contemporary techniques, the benefits of temporary transvenous pacing do not appear to outweigh the risks in mildly to moderately symptomatic patients particularly if episodes of SND are intermittent and not associated with hemodynamic compromise.

Figure 5. Acute pacing algorithm. Colors correspond to Class of Recommendation in Table 2. See Sections 5.4. and 6.3. for discussion. *Refer to Section 5.4.4.1., Figure 6, for chronic SND and Section 6.4., Figure 7, for chronic atrioventricular block. †Careful management of anesthesia to avoid or minimize the use of drugs associated with bradycardia is required.

Recommendations for Temporary Pacing for Bradycardia Attributable to SND (Continued)

COR LOE Recommendations

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