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2.3.3 Changes in cardiac pacing and cardiac resynchronization therapy guideline recommendations since 2013

3 Background

3.1 Epidemiology

The prevalence and incidence of pacemaker implantation are unknown in many countries, yet several estimations have been published based on the analysis of large observational studies and databases. There is considerable variability in reported pacemaker implant rates between European countries, ranging from <25

Patient-centred care In patients considered for pacemaker or CRT, the decision should be based on the best available evidence with consideration of individual risk-benefits of each option, the patients preferences, and goals of care, and it is recommended to follow an integrated care approach and use the principles of patientcentred care and shared decision making in the consultation. I C

AF = atrial fibrillation; ATP = antitachycardia pacing; AV = atrioventricular; AVB = atrioventricular block; AVJ = atrioventricular junction; BBB = bundle branch block; BMI = body mass index; CIED = cardiovascular implantable electronic device; CMR = cardiovascular magnetic resonance; CRT = cardiac resynchronization therapy; CRT-D = defibrillator with cardiac resynchronization therapy; CRT-P = cardiac resynchronization therapy-pacemaker; CSM = carotid sinus massage; CT = computed tomography; DDD = dual-chamber, atrioventricular pacing; ECG = electrocardiogram; EPS = electrophysiology study; HBP = His bundle pacing; HF = heart failure; HFmrEF = heart failure with mildly reduced ejection fraction; HFpEF = heart failure with preserved ejection fraction; HV = Hisventricular interval; ICD = implantable cardioverter-defibrillator; ILR = implantable loop recorder; LBBB = left bundle branch block; LV = left ventricular; LVEF = left ventricular ejection fraction; MI = myocardial infarction; MRI = magnetic resonance imaging; OMT = optimal medical therapy; PET = positron emission tomography; PR = PR interval; QRS = Q, R, and S waves; RBBB = right bundle branch block; RV = right ventricular; SAS = sleep apnoea syndrome; SND = sinus node dysfunction; SR = sinus rhythm; TAVI = transcatheter aortic valve implantation. aClass of recommendation. bLevel of evidence. cCSM should not be undertaken in patients with previous transient ischaemic attack, stroke, or known carotid stenosis. Carotid auscultation should be performed before carotid sinus massage. If a carotid bruit is present, carotid ultrasound should be performed to exclude carotid disease dComplete blood counts, prothrombin time, partial thromboplastin time, serum creatinine, and electrolytes. eImmediately after procedure or within 24 h. fTransient high-degree AVB, PR prolongation, or QRS axis change. gAmbulatory continuous ECG monitoring (implantable or external) for 730 days. hElectrophysiology study with HV >_70 ms may be considered positive for permanent pacing. iWhenever pacing is indicated in neuromuscular disease, an ICD should be considered according to relevant guidelines. ESC 2021

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Table 5 Changes in cardiac pacing and cardiac resynchronization therapy guideline recommendations since 2013

2013 2021

Classa

Cardiac pacing for bradycardia and conduction system disease In patients with syncope, cardiac pacing may be considered to reduce recurrent syncope when asymptomatic pause(s) >6 s due to sinus arrest are documented. IIa IIb

Continued Cardiac resynchronization therapy

Patients who have received a conventional pacemaker or an ICD and who subsequently develop symptomatic HF with LVEF <_35% despite OMT and who have a significantb proportion of RV pacing should be considered for upgrade to CRT. I IIa CRT rather than RV pacing is recommended for patients with HFrEF (<40%) regardless of NYHA class who have an indication for ventricular pacing and high-degree AVB in order to reduce morbidity. This includes patients with AF. IIa I CRT should be considered for symptomatic patients with HF in SR with LVEF <_35%, a QRS duration of 130149 ms, and LBBB QRS morphology despite OMT, to improve symptoms and reduce morbidity and mortality. I IIa In patients with symptomatic AF and uncontrolled heart rate who are candidates for AVJ ablation (irrespective of QRS duration), CRT is recommended in patients with HFrEF. IIa I Specific indications for pacing In patients with congenital heart disease, pacing may be considered for persistent postoperative bifascicular block associated with transient complete AVB. IIa IIb Management considerations In patients with MRI-conditional pacemaker systemsc, MRI can be performed safely following manufacturer instructions. IIa I In patients with non-MRI-conditional pacemaker systems, MRI should be considered if no alternative imaging mode is available and if no epicardial leads, abandoned or damaged leads, or lead adaptors/extenders are present. IIb IIa

AF = atrial fibrillation; AVB = atrioventricular block; AVJ = atrioventricular junction; CRT = cardiac resynchronization therapy; HFrEF = heart failure with reduced ejection fraction; ICD = implantable cardioverter-defibrillator; LBBB = left bundle branch block; LVEF = left ventricular ejection fraction; MRI = magnetic resonance imaging; NYHA = New York Heart Association; OMT = optimal medical therapy; RV = right ventricular; SR = sinus rhythm. aClass of recommendation. bA limit of 20% RV pacing for considering interventions for pacing-induced HF is supported by observational data. However, there are no data to support that any percentage of RV pacing can be considered as defining a true limit below which RV pacing is safe and beyond which RV pacing is harmful. cCombination of MRI conditional generator and lead(s) from the same manufacturer. ESC 2021

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