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No one in Los Angeles has more experiences with pacemakers than Dr. Uri-Ben-Zur. If you feel faint or dizzy at all, please make an appointment to see us today at the Cardiovascular Institute of Greater Los Angeles.

 

Task Force of the American College of Cardiology indications for Pacemakers:

Guidelines for pacemakers have been established by a task force formed by the American College of Cardiology. There are two major reasons for permanent pacemaker insertion: patients with symptoms stemming from an arrhythmia and the location of the abnormality

Patients need to have symptoms correlated with an arrhythmia. For instance, a correlation between bradyarrhythmias with the symptoms of dizziness, syncope, shortness of breath and confusion must be established. In addition, the location of the abnormality needs to be considered. Pacemakers are indicated for individuals with conduction abnormalities at the AV node or below.

Class I — The following conditions represent severe conduction disease and are generally considered to be class I indications for pacing:

  • Complete (third-degree) AV block
  • Advanced second-degree AV block (block of two or more consecutive P waves)
  • Symptomatic Mobitz I or Mobitz II second-degree AV block
  • Mobitz II second-degree AV block with a widened QRS or chronic bifascicular block, regardless of symptoms
  • Exercise-induced second- or third-degree AV block (in the absence of myocardial ischemia)

Sinus bradycardia in which symptoms are clearly related to the bradycardia (usually in patients with a heart rate below 40 beats/min or frequent sinus pauses). (Sick Sinus Syndrome)

  • Symptomatic chronotropic incompetence.

 

 

Class II — Patients with less severe forms of acquired AV block may still benefit from pacemaker placement. In such patients, determinations are often based upon correlation of bradycardia with symptoms, exclusion of other causes of symptoms, and uncommonly based on results of electrophysiology (EP) testing.

Conditions in which pacemaker placement can be considered include the following:

  • Asymptomatic Mobitz II second-degree AV block with a narrow QRS interval; patients with associated symptoms or a widened QRS interval have a class I indication for pacemaker placement.
  • First-degree AV block when there is hemodynamic compromise because of effective AV dissociation secondary to a very long PR interval.
  • Bifascicular or trifascicular block associated with syncope that can be attributed to transient complete heart block, based upon the exclusion of other plausible causes of syncope, even if syncope isn’t correlated with AV block (specifically ventricular tachycardia)
  • Sinus bradycardia (heart rate <40 beats/min) in a patient with symptoms suggestive of bradycardia, but without a clearly demonstrated association between bradycardia and symptoms.
  • Sinus node dysfunction in a patient with unexplained syncope.
  • Chronic heart rates <40 beats/min while awake in a minimally symptomatic patient.
  • A less distinct group of patients with sinus bradycardia of lesser severity (heart rate >40 beats/min) who complain of dizziness or other symptoms that correlate with the slower rates.

REFERENCES

  1. Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Circulation 2008; 117:e350.
  2. Tracy CM, Epstein AE, Darbar D, et al. 2012 ACCF/AHA/HRS focused update of the 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. [corrected]. Circulation 2012; 126:1784.
  3. Vardas PE, Auricchio A, Blanc JJ, et al. Guidelines for cardiac pacing and cardiac resynchronization therapy. The Task Force for Cardiac Pacing and Cardiac Resynchronization Therapy of the European Society of Cardiology. Developed in collaboration with the European Heart Rhythm Association. Europace 2007; 9:959.
  4. Birnie D, Williams K, Guo A, et al. Reasons for escalating pacemaker implants. Am J Cardiol 2006; 98:93.
  5. Hayes DL, Barold SS, Camm AJ, Goldschlager NF. Evolving indications for permanent cardiac pacing: an appraisal of the 1998 American College of Cardiology/American Heart Association Guidelines. Am J Cardiol 1998; 82:1082.
  6. Recommendations for pacemaker prescription for symptomatic bradycardia. Report of a working party of the British Pacing and Electrophysiology Group. Br Heart J 1991; 66:185.
  7. Zeltser D, Justo D, Halkin A, et al. Drug-induced atrioventricular block: prognosis after discontinuation of the culprit drug. J Am Coll Cardiol 2004; 44:105.
  8. Scheinman MM, Peters RW, Suavé MJ, et al. Value of the H-Q interval in patients with bundle branch block and the role of prophylactic permanent pacing. Am J Cardiol 1982; 50:1316.
  9. Dhingra RC, Wyndham C, Bauernfeind R, et al. Significance of block distal to the His bundle induced by atrial pacing in patients with chronic bifascicular block. Circulation 1979; 60:1455.
  10. European Heart Rhythm Association, Heart Rhythm Society, Zipes DP, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). J Am Coll Cardiol 2006; 48:e247.

Groh WJ. Arrhythmias in the muscular dystrophies. Heart Rhythm 2012; 9:1890.

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