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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 e450 CLINICAL STATEMENTS AND GUIDELINES include family with patient permission, or the patient’s family or surrogate if the patient does not have capacity. 12 QUALITY OF LIFE Among patients with indications for PPM implantation for either shared decision-making or atrioventricular block, QOL improves substantially after pacemaker implantation,S12-1–S12-5 but the benefits of different pacing modes (such as dual chamber pacing versus single chamber pacing) are inconsistent. In the CTOPP trial, for example, there was no significant difference in improvement in QOL between patients with dual chamber and single chamber pacing.S12-4 In the PASE trial, however, although there were no overall benefits of dual chamber over single chamber pacing in terms of QOL, dual chamber pacing did appear to result in better QOL in the subgroup with shared decision-making.S12-3 In the MOST trial, in addition to the benefits of less AF and heart failure, dual chamber pacing was associated with modest improvements in some QOL indices, especially among younger patients.S12-1,S12-2 In small crossover studies, improvements in measures of QOL were found with dual chamber pacing in some,S12-6–S12-9 but not all studies.S12-10 In the nonrandomized FOLLOWPACE observational study, over a mean follow-up of 7.5 years, pacing was associated with long-term improvement in QOL, but there were no apparent differences based on mode of pacing.S12-5 13 DISCONTINUATION OF PACEMAKER THERAPY Recommendation for Discontinuation of Pacemaker Therapy COR LOE Recommendation IIa C-LD 1. In patients who present for pacemaker pulse generator replacement, or for management of pacemaker related complications, in whom the original pacing indication has resolved or is in question, discontinuation of pacemaker therapy is reasonable after evaluation of symptoms during a period of monitoring while pacing therapy is off.S13-1,S13-2 Synopsis Prior recommendations have been provided for implantation of PPMs.S13-3 Yet, the decision to not replace a pacemaker is more difficult. No guidelines previously existed for the removal of PPMs and the termination of long-term cardiac pacing. In general, most patients with pacemakers at end of battery life or with lead or device malfunction undergo replacement or revision without questioning the need for continued pacing. However, physicians occasionally encounter patients referred for pacemaker surgery or with pacemaker related complications that do not appear to have a persistent need for pacing because the original indication is unclear, questionable, or appears to have resolved.S13-4,S13-5 Furthermore, several studies have estimated that approximately 30% of pacemakers have been implanted for other than Class I and IIa indications.S13-4,S13-6 In this group of patients, in whom the continued need for pacing is questioned, the process required to discontinue pacing therapy is unclear. Although the decision of not replacing a pacemaker is a difficult one, especially because the natural history of bradycardia can be unpredictable, it has to be balanced against the risk of long-term pacemaker related complications over a lifetime. In such patients, options for discontinuation of pacemaker therapy could include programming the pacemaker “off,” elective nonreplacement of a device approaching end of battery service life, explant of the pulse generator alone, and in some cases, pulse generator explant and extraction of the lead(s). Recommendation-Specific Supportive Text 1. In 1 study, 5 patients referred for pacemaker replacement or a pacemaker related complication in which the original indication for pacing appeared to have resolved, intrinsic rhythm was documented and 2 underwent EPS.S13-1 The pacemakers were removed from all 5 patients and none had symptomatic bradycardia after 18 to 48 months of follow-up.S13-1 One group of investigators developed a protocol that was used to discontinue pacing therapy in 70 patients without a clear initial or persistent indication. The protocol included clinical evaluation, echocardiogram, exercise testing, and tilt table testing. If these tests were negative, the pulse generator energy was turned to off, with periodic 24-hour ambulatory electrocardiographic monitoring for up to 1 year, after which an EPS was conducted. Of the 70 patients, 35 had their pacemaker explanted; after a mean follow-up of 30.3 months all patients remained asymptomatic, except for 1 patient who died of a non-cardiac cause.S13-2 In a retrospective study of patients who underwent lead extraction without device replacement, mortality appeared to be dependent on comorbid conditions, and arrhythmia related death was rare.S13-7 14 END-OF-LIFE CONSIDERATIONS Healthcare professionals frequently face questions about pacemaker deactivation in patients nearing end of life. Although patients and families often fear that Downloaded from http://ahajournals.org by on October 7, 2026