Guideline-based Indications for Pacemakers and Resynchronization

Indications for Pacemaker (Class I and IIa/b Recommendations)

  • Sinus node dysfunction (SND) with symptomatic bradycardia
  • Symptomatic chronotropic incompetence
  • Required drug therapy causing symptomatic bradycardia
  • SND with HR < 40 bpm;  bradycardia and symptom connection unclear
  • Unexplained syncope and EP study (+) for SND
  • Conisder for minimal symptoms but HR < 40 bpm while awake
  • Type II second-degree AV block, or complete third-degree AV block with:
    • Bradycardia + symptoms
    • Arrhythmias + required bradycardic meds
    • Asymptomatic awake with pauses > 3 sec, Asymptomatic awake with v-rate < 40 bpm, Asymptomatic awake with infra-His conduction
    • Asymptomatic awake with AF and > 5 sec pauses
    • After catheter ablation of AV junction
    • Post-operative AVB not expected to resolve
    • Neuromuscular:  myotonic dystrophy, Kearns-Sayre, Erb dystrophy, peroneal muscular atrophy
  • Symptomatic bradycardia + second-degree AVB
  • Asymptomatic bradycardia + type II second-degree AVB (narrow or wide QRS)
  • Asymptomatic second-degree AVB at intra or infra His level on EP study
  • Asymptomatic complete third-degree AVB with:
    • V-rate < 40 bpm
    • LV dysfunction
    • Site of block below AV node
    • Reasonable in V-rate > 40 and persistent
  • First or Second Degree AVB with:
    • Pacemaker syndrome
    • Hemodynamic compromise
  • Muscular dystrophy of any AV block, with or without symptoms
  • Recurrence of AVB is expected after offending drug is withdrawn
  • Advanced second-degree AVB or third-degree AVB
  • Type II 2nd degree AVB
  • Alternating Bundle Branch Block
  • Syncope of unknown type after exclusion of other causes including VT
  • HV > 100 msec, even if asymptomatic
  • EP study with infra-Hisian block, even if non-physiological
  • After STEMI with: persistent 2nd/3rd DAVB regardless of symptoms, transient infranodal AVB
  • Carotid sensitivity causing syncope and ventricular asystole > 3 sec
  • Hypersensitive cardioinhibition > 3 sec with syncope of unclear trigger
  • Neurocardiogenic syncope (symptomatic!) and bradycardia on tilt-table testing 
  • Post-transplant hearts with inappropriate or symptomatic bradycardia (permanent)
  • Post-transplant with syncope
  • Post-transplant with bradycardia that limits cardiac rehab
  • Symptomatic recurrent SVT that responds/terminates with pacing
  • Prevention of pause-dependent VT
  • Congenital long-QT patients at high risk
  • Prevention of recurrent refractory AF in patients with SND
  • HoCM with significant symptomatic outflow tract obstruction (at rest or provoked)
  • Children with age-inappropriate bradycardia
  • Congenital third-degree AV block in the infant with V-rate < 55 bpm or with congenital heart disease and a V-rate < 70 bpm.


Contraindications for Pacemaker

  • Asymptomatic patients
  • Symptoms and bradycardia clearly do not overlap
  • Drugs causing bradycardia are not essential and can be changed
  • Bradycardia and/or AV block associated with obstructive sleep apnea (OSA, reversible)
  • Asymptomatic first-degree AV block
  • Supra-Hisian Wenckebach block
  • Reversible AV block:  Lyme, drug toxicity, OSA, transient vagal tone changes
  • Fascicular block without AVB (or only 1st degree AVB) and without symptoms
  • Post-MI with: transient AVB above ventricle, transient AVB and only LAFB, only fascicular block, 1st dDAVB with BBB or fascicular block
  • Asymptomatic hypersensitive neurocardioinhibition
  • Avoidable vasovagal syncope (symptoms controlled by modifying behavior)
  • Accessory pathway with antegrade rapid conduction 
  • Frequent/complex PVC/NSVT in the absence of congenital LQT
  • Torsades de pointes
  • Only for the prevention of AF
  • Asymptomatic HoCM, Symptomatic HoCM without evidence of outflow tract obstruction
  • Transient post-Op block in a child
  • Asymptomatic 1st DAVB or fascicular block in child with congenital HD





Indications for Cardiac Resynchronization Therapy

  • LVEF ≤ 35% on GDMT, sinus, LBBB, QRS > 120 ms, NYHA II-IV
  • LVEF ≤ 35% on GDMT, sinus, non-LBBB, QRS > 150 ms (120-150 possibly), NYHA III-IV
  • LVEF ≤ 35% on GDMT, AF, V-pacing expected near 100%
  • LVEF ≤ 35%, V-pacing expected > 40%
  • NYHA I, only if LVEF ≤ 30%, in sinus, on GDMT, and LBBB QRS > 150 ms 
  • NYHA II non-LBBB, only if LVEF ≤35%, sinus on GDMT, and QRS > 150 ms


Contraindications for Cardiac Resynchronization Therapy

  • NYHA I or II, non-LBBB, QRS < 150 ms
  • < 1 year of expected survival with good functional capacity




Indications for ICD Therapy

  • Survivors of cardiac arrest after reversible causes excluded
  • Structural HD + spontaneous sustained VT
  • Syncope + positive EPS for VT/VF
  • > 40 days post-MI with LVEF ≤ 35% and NYHA II-III
  • Dilated cardiomyopathy LVEF ≤ 35% and NYHA II-III
  • NYHA I, if LVEF ≤ 30%,  > 40 d post MI
  • NYHA I, if LVEF ≤ 35%, non-ischemic CMP
  • Prior MI, LVEF ≤ 40%, EPS inducible VT/VF
  • Unexplained syncope, significant LV dysfunction, non-ischemic DCM
  • Sustained VT
  • 1+ SCD risk factors:
  • ARVC/D and 1+ risk factors
  • LQT on beta blockers who have syncope or VT
  • LQT and SCD risk factors
  • Awaiting transplant at home
  • Brugada Syndrome with syncope or VT
  • CPVT on beta blockers who have syncope or VT
  • Dx of:  cardiac sarcoidosis, giant cell myocarditis, Chagas
  • Syncope and advanced structural heart disease
  • Familial cardiomyopathy associated with SCD
  • LV non-compaction cardiomyopathy
  • Congenital HD with syncope of undetermined origin and with either ventricular dysfunction or arrhythmias


Contraindications for ICD

  • < 1 year expected survival with poor functional class
  • Incessant VT/VF
  • Psychiatric illness that interferes with symptoms/follow-up
  • NYHA Class IV patients with drug-refractory congestive heart failure who are not candidates for cardiac transplantation or CRT-D.
  • Syncope unknown cause and negative EPS for VT/VF
  • VF or VT is amenable to surgical or catheter ablation (e.g., atrial arrhythmias associated with the Wolff-Parkinson-White syndrome, RV or LV outflow tract VT, idiopathic VT, or fascicular VT in the absence of structural heart disease)
  • Completely reversible cause of VT/VF (acute MI,  electrolytes, trauma, drugs)
  • < 40 days post MI,  < 90 days post-revascularization, < 90 days after HF GDMT




2012 ACC/AHA Guidelines for Device-Based Therapy




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