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Kusumoto et al 2018 Bradycardia Clinical Practice Guidelines

August 20, 2019 Circulation. 2019;140:e382–e482. DOI: 10.1161/CIR.0000000000000628 e430

CLINICAL STATEMENTS AND GUIDELINES IIa B-RSR 4.  In patients with atrioventricular block who have an indication for permanent pacing with a LVEF between 36% and 50% and are expected to require ventricular pacing more than 40% of the time, it is reasonable to choose pacing methods that maintain physiologic ventricular activation (eg, cardiac resynchronization therapy [CRT] or His bundle pacing) over right ventricular pacing.S6.4.4.1-7,S6.4.4.1-11–S6.4.4.1-19

IIa B-R 5.  In patients with atrioventricular block who have an indication for permanent pacing with a LVEF between 36% and 50% and are expected to require ventricular pacing less than 40% of the time, it is reasonable to choose right ventricular pacing over pacing methods that maintain physiologic ventricular activation (eg, CRT or His bundle pacing).S6.4.4.1-15,S6.4.4.1-16,S6.4.4.1-20,S6.4.4.1-21

IIb B-RSR 6.  In patients with atrioventricular block at the level of the atrioventricular node who have an indication for permanent pacing, His bundle pacing may be considered to maintain physiologic ventricular activation.S6.4.4.1-19,S6.4.4.1-22–S6.4.4.1-25

III: Harm C-LD 7.  In patients with permanent or persistent AF in whom a rhythm control strategy is not planned, implantation of an atrial lead should not be performed.S6.4.4.1-26,S6.4.4.1-27 SR indicates systematic review.

Synopsis

Refer to “Systematic Review for the 2018 ACC/AHA/ HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay” for the complete systematic evidence review,S6.4.4.1-19 and the Online Data Supplement for additional data and analyses. The results from the question “Impact of Physiologic Versus Right Ventricular Pacing Among Patients With Left Ventricular Ejection Fraction Greater Than 35%” and the writing committee’s review of the totality of the literature were used to frame recommendations. Recommendations that are based on a body of evidence that includes the systematic review conducted by the evidence review committee are denoted by the superscript SR (eg, LOE: B-RSR). The effects of pacing mode on outcomes in patients with atrioventricular block have also been reviewed in a recent expert consensus statement.S6.4.4.1-28 In older observational studies, patients with highgrade atrioventricular block often had syncope and heart failure symptoms prompting pacemaker implantation, although sudden death attributable to atrioventricular block was not commonly reported.S6.4.4.1-29–S6.4.4.1-31 There are several RCTs that looked at the possible benefits of dual chamber pacing for atrioventricular block compared with ventricular pacing but neither improvements in all-cause mortality nor cardiovascular mortality were demonstrated.S6.4.4.1-1–S6.4.4.1-5,S6.4.4.1-8 However, regardless of pacing technique, patients with atrioventricular block will require ventricular pacing for rate support. Specialized pacing modalities, such as biventricular pacing or His bundle pacing may alleviate the deleterious effects of right ventricular pacing in these patients. When determining the type of pacemaker (single, dual, biventricular), many patient factors should be considered including the projected percent of ventricular pacing and the LVEF. As addressed in the 2013 ACCF/AHA guideline for the management of heart failure, biventricular pacing can be useful for the patient on guideline-directed management and therapy who has an LVEF of ≤35% with an anticipated requirement for significant ventricular pacing (>40%).S6.4.4.1-32

Recommendation-Specific Supportive Text

1.	 PASE (Pacemaker Selection in the Elderly), MOST (Mode Selection Trial in Sinus Node Dysfunction), and CTOPP (Canadian Trial of Physiologic Pacing) were RCTs that enrolled subjects indicated for a pacemaker with SND or atrioventricular block, or both, and compared dual chamber pacing or pacing modes that maintained atrioventricular synchrony with single chamber ventricular pacing.S6.4.4.1-1–S6.4.4.1-4,S6.4.4.1-6 These trials did not demonstrate a reduction in all-cause mortality or stroke. The PASE investigators did a subgroup analysis and found no difference in functional status or QOL life for the atrioventricular block patients but did find that the SND patients with dual chamber pacing had improved functional status after 18 months of pacing therapy compared with single chamber ventricular pacing patients. These RCTs also showed a lower incidence of AF in the dual chamber patients.S6.4.4.1-28 A comprehensive Cochrane review looking at pacing mode and outcomes concluded that dual chamber pacing is preferred because of a smaller incidence of AF and because of the prevalence of pacemaker syndrome with single chamber ventricular pacing.S6.4.4.1-5 Clinical situations where it may be reasonable to implant a single chamber ventricular pacing device include patients with frailty or significant comorbidities, advanced age, a very sedentary lifestyle, difficulty placing the atrial lead and very infrequent episodes where pacing would be needed. 2.	 UKPace (United Kingdom Pacing and Cardiovascular Events), an RCT that only enrolled elderly patients with atrioventricular block and compared dual chamber with single chamber

Recommendations for Permanent Pacing Techniques and Methods for Chronic Therapy/Management of Bradycardia Attributable to Atrioventricular Block (Continued)

COR LOE Recommendations

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