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Be ́la Merkely (Hungary), Christoph Starck (Germany), Ingela Thyle ́n (Sweden), Jose ́ Maria Tolosana (Spain), ESC Scientific Document Group

Document Reviewers: Francisco Leyva (CPG Review Coordinator) (United Kingdom), Cecilia Linde (CPG Review Coordinator) (Sweden), Magdy Abdelhamid (Egypt), Victor Aboyans (France), Elena Arbelo (Spain), Riccardo Asteggiano (Italy), Gonzalo Baron-Esquivias (Spain), Johann Bauersachs (Germany), Mauro Biffi(Italy), Ulrika Birgersdotter-Green (United States of America ), Maria Grazia Bongiorni (Italy), Michael A. Borger (Germany), Jelena Celutkien _e (Lithuania), Maja Cikes (Croatia), Jean-Claude Daubert (France), Inga Drossart (Belgium), Kenneth Ellenbogen (United States of America), Perry M. Elliott (United Kingdom), Larissa Fabritz (United Kingdom), Volkmar Falk (Germany), Laurent Fauchier (France), Francisco Fernandez-Avile ́s (Spain), Dan Foldager (Denmark), Fredrik Gadler (Sweden), Pastora Gallego Garcia De Vinuesa (Spain), Bulent Gorenek (Turkey), Jose M. Guerra (Spain), Kristina Hermann Haugaa (Norway), Jeroen Hendriks (Netherlands), Thomas Kahan (Sweden), Hugo A. Katus (Germany), Aleksandra Konradi (Russia), Konstantinos C. Koskinas (Switzerland), Hannah Law (United Kingdom), Basil S. Lewis (Israel), Nicholas John Linker (United Kingdom), Maja-Lisa Løchen (Norway), Joost Lumens (Netherlands), Julia Mascherbauer (Austria), Wilfried Mullens (Belgium), Klaudia Vivien Nagy (Hungary), Eva Prescott (Denmark), Pekka Raatikainen (Finland), Amina Rakisheva (Kazakhstan), Tobias Reichlin (Switzerland), Renato Pietro Ricci (Italy), Evgeny Shlyakhto (Russia), Marta Sitges (Spain), Miguel Sousa-Uva (Portugal), Richard Sutton (Monaco), Piotr Suwalski (Poland), Jesper Hastrup Svendsen (Denmark), Rhian M. Touyz (United Kingdom), Isabelle C. Van Gelder (Netherlands), Kevin Vernooy (Netherlands), Johannes Waltenberger (Germany), Zachary Whinnett (United Kingdom), Klaus K. Witte (United Kingdom) All experts involved in the development of these guidelines have submitted declarations of interest. These have been compiled in a report and published in a supplementary document simultaneously to the guidelines. The report is also available on the ESC website www.escardio.org/guidelines For the Supplementary Data which include background information and detailed discussion of the data that have provided the basis for the guidelines see European Heart Journal online

................................................................................................................................................................................................... Keywords Guidelines • cardiac pacing • cardiac resynchronization therapy • pacemaker • heart failure • syncope • atrial fibrillation • conduction system pacing • pacing indications • alternate site pacing • complications • pacing in TAVI • bradycardia • temporary pacing

Table of contents

1 Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 2 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 2.1 Evidence review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 2.2 Relationships with industry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 2.3 What is new in these guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 2.3.1 New concepts and new sections . . . . . . . . . . . . . . . . . . . . . . . . . . 8 2.3.2 New recommendations in 2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 2.3.3 Changes in cardiac pacing and cardiac resynchronization therapy guideline recommendations since 2013 . . . . . . . . . . . . . . . . 11 3 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 3.1 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 3.2 Natural history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 3.3 Pathophysiology and classification of bradyarrhythmias considered for permanent cardiac pacing therapy . . . . . . . . . . . . . . . . 12 3.4 Types and modes of pacing: general description . . . . . . . . . . . . . . . 13 3.4.1 Endocardial pacing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 3.4.2 Epicardial pacing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 3.4.3 Cardiac resynchronization therapy (endo-and/or epicardial) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 3.4.4 Alternative methods (conduction system pacing, leadless pacing) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

3.4.4.1 Conduction system pacing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 3.4.4.2 Leadless pacing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 3.4.5 Pacing modes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 3.4.6 Rate-responsive pacing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 3.5 Sex differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 4 Evaluation of the patient with suspected or documented bradycardia or conduction system disease . . . . . . . . . . . . . . . . . . . . . . . . . . 14

4.1 History and physical examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 4.2 Electrocardiogram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 4.3 Non-invasive evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 4.3.1 Ambulatory electrocardiographic monitoring . . . . . . . . . . . . . 16 4.3.2 Exercise testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 4.3.3 Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 4.3.4 Laboratory tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 4.3.5 Genetic testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Downloaded from academic.oup.com/eurheartj/article/42/35/3427/6358547 by guest on 07 October 2026