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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 e386

CLINICAL STATEMENTS AND GUIDELINES 1.2 Organization of the Writing

Committee

The writing committee consisted of cardiac electrophysiologists, clinicians, cardiologists, surgeons, an anesthesiologist, and a lay/patient representative. The writing committee included representatives from the ACC, AHA, Heart Rhythm Society (HRS), American Association for Thoracic Surgery (AATS), Pediatric & Congenital Electrophysiology Society (PACES), and the Society of Thoracic Surgeons (STS). Appendix 1 of the present document lists writing committee members’ relevant RWI. For the purposes of full transparency, the writing committee members’ comprehensive disclosure information is available online).

1.3 Document Review and Approval

This document was reviewed by 2 official reviewers each nominated by the ACC, AHA, and HRS; 1 official lay reviewer nominated by the AHA; 1 organizational reviewer each from the AATS, PACES, and STS; and 31 individual content reviewers. Reviewers’ RWI information was distributed to the writing committee and is published as an abbreviated table in this document (Appendix 2). The reviewers’ detailed RWI information is available online. This document was approved for publication by the governing bodies of the ACC, the AHA, and the HRS; and was endorsed by the American Association for Thoracic Surgery, the Pediatric & Congenital Electrophysiology Society, and the Society of Thoracic Surgeons.

1.4 Scope of the Guideline

The purpose of this ACC/AHA/HRS guideline is to provide guidance to clinicians for the management of patients with bradycardia, or symptoms thought to be associated with bradycardia or cardiac conduction system disorders. This guideline supersedes the pacemaker recommendations made in the “ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities”S1.4-1,S1.4-2 and “2012 ACCF/AHA/HRS Focused Update Incorporated Into the ACCF/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities.”S1.4-2 The guideline will be useful to general internists, family physicians, emergency physicians, anesthesiologists, surgeons, cardiologists, and arrhythmia specialists. This document is aimed at the adult population (>18 years of age) and offers no specific recommendations in pediatric patients, although some of the evidence review included pediatric patients. Although background on the pathophysiology and epidemiology of bradycardia and cardiac conduc- tion disorders is summarized, this guideline is not intended to be an exhaustive review. Rather, it focuses on practical clinical evaluation and management. Specific objectives and goals include:

•	 Describe the clinical significance of bradycardia with respect to mortality, symptoms (eg, syncope, impaired functional capacity), and exacerbations of associated disorders (eg, ischemia, heart failure, provoked tachyarrhythmias). •	 Address inherited and acquired disorders of the sinus node, atrioventricular node, His-Purkinje fibers, and intramyocardial conducting tissue, including the effects of medications, aging, metabolic derangements, trauma, radiation, infiltrative, ischemic, and inflammatory disorders, infectious and toxic agents, and iatrogenic factors. •	 Delineate the clinical presentation and general approach to clinical evaluation of patients with overt or suspected bradycardias or conduction diseases. •	 Comprehensively evaluate the evidence supporting recommendations for the selection and timing of available diagnostic testing modalities, including monitoring devices and electrophysiologic testing. •	 Define the evidence base supporting recommendations for the use of available treatment modalities, including lifestyle interventions, pharmacotherapy, and external and implanted device-based therapies, with particular attention to indications for temporary and permanent pacing. •	 Address special considerations that may be applicable to distinct populations based on age (>18 years of age), comorbidities or other relevant factors. •	 Identify knowledge gaps, pertinent trials in progress and directions for future research. Table 1 lists other guidelines and pertinent documents that the writing committee considered for this guideline. The listed documents contain relevant information for the management of patients with bradycardia or cardiac conduction system disorder.

1.5 Class of Recommendation and Level

of Evidence

Recommendations are designated with both a class of recommendation (COR) and a level of evidence (LOE). The class of recommendation indicates the strength of recommendation, encompassing the estimated magnitude and certainty of benefit in proportion to risk. The level of evidence rates the quality of scientific evidence supporting the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources (Table 2).S1.5-1

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