2018 ACC/AHA/HRS - Journal of the American College of Cardiology

2018 ACC/AHA/HRS - Journal of the American College of Cardiology

2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay Developed in Collaboration With and Endorsed by the American Association for Thoracic Surgery, the Pediatric & Congenital Electrophysiology Society, and the Society of Thoracic Surgeons American College of Cardiology Foundation and American Heart Association Citation This slide set is adapted from the 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay. Published on November 6, 2018, available at: Journal of the American College of Cardiology [(insert full link)] and Circulation [(insert full link)] The full-text guidelines are also available on the following Web sites: ACC (www.acc.org) and AHA (professional.heart.org) Bradycardia Guideline Writing Committee Fred M. Kusumoto, MD, FACC, FAHA, FHRS, Chair Mark H. Schoenfeld, MD, FACC, FAHA, FHRS, Vice Chair Coletta Barrett, RN, FAHA Richard Lee, MD, MBA# James R. Edgerton, MD, FACC, FHRS

Joseph E. Marine, MD, MBA, FACC, FHRS Kenneth A. Ellenbogen, MD, FACC, FAHA, FHRS* Christopher J. McLeod, MB, ChB, PhD, FACC, FAHA, FHRS Michael R. Gold, MD, PhD, FACC* Keith R. Oken, MD, FACC Nora F. Goldschlager, MD, FACC, FAHA, FHRS Kristen K. Patton, MD, FACC, FAHA, FHRS Robert M. Hamilton, MD Cara N. Pellegrini, MD, FHRS*** Jos A. Joglar, MD, FACC, FAHA, FHRS Kimberly A. Selzman, MD, MPH, FACC, FHRS Robert J. Kim, MD Annemarie Thompson, MD Paul D. Varosy, MD, FACC, FAHA, FHRS ACC/AHA Representative. STS Representative. HRS Representative. PACES Representative. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. #AATS Representative. **Dr. Pellegrini contributed to this article in her personal capacity. The views expressed are her own and do not necessarily represent the views of the U.S. Department of Veterans Affairs or the U.S. government. ACC/AHA Performance Measures Representative Table 1. Applying Class

of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care* (Updated August 2015) Top 10 Take-Home Messages Top 10 Take Home Messages 1. Sinus node dysfunction is most often related to agedependent progressive fibrosis of the sinus nodal tissue and surrounding atrial myocardium leading to abnormalities of sinus node and atrial impulse formation and propagation and will therefore result in various bradycardic or pause-related syndromes. Top 10 Take Home Messages 2. Both sleep disorders of breathing and nocturnal bradycardias are relatively common, and treatment of sleep apnea not only reduces the frequency of these arrhythmias but also may offer cardiovascular benefits. The presence of nocturnal bradycardias should prompt consideration for screening for sleep apnea, beginning with solicitation of suspicious symptoms. However, nocturnal bradycardia is not in itself an indication for permanent pacing. Top 10 Take Home Messages 3. The presence of left bundle branch block on

electrocardiogram markedly increases the likelihood of underlying structural heart disease and of diagnosing left ventricular systolic dysfunction. Echocardiography is usually the most appropriate initial screening test for structural heart disease, including left ventricular systolic dysfunction. Top 10 Take Home Messages 4. In sinus node dysfunction, there is no established minimum heart rate or pause duration where permanent pacing is recommended. Establishing temporal correlation between symptoms and bradycardia is important when determining whether permanent pacing is needed. Top 10 Take Home Messages 5. In patients with acquired second-degree Mobitz type II atrioventricular block, high-grade atrioventricular block, or third-degree atrioventricular block not caused by reversible or physiologic causes, permanent pacing is recommended regardless of symptoms. For all other types of atrioventricular block, in the absence of conditions associated with progressive atrioventricular conduction abnormalities, permanent pacing should generally be considered only in the presence of symptoms that correlate with atrioventricular block. Top 10 Take Home Messages 6. In patients with a left ventricular ejection fraction between 36% to 50% and atrioventricular block, who have an indication for permanent pacing and are expected to require ventricular pacing >40% of the time, techniques that provide more physiologic ventricular activation (e.g., cardiac resynchronization therapy, His bundle pacing) are preferred to right ventricular pacing to prevent heart failure.

Top 10 Take Home Messages 7. Because conduction system abnormalities are common after transcatheter aortic valve replacement, recommendations on postprocedure surveillance and pacemaker implantation are made in this guideline. Top 10 Take Home Messages 8. In patients with bradycardia who have indications for pacemaker implantation, shared decision-making and patientcentered care are endorsed and emphasized in this guideline. Treatment decisions are based on the best available evidence and on the patients goals of care and preferences. Top 10 Take Home Messages 9. Using the principles of shared decision-making and informed consent/refusal, patients with decision-making capacity or his/ her legally defined surrogate has the right to refuse or request withdrawal of pacemaker therapy, even if the patient is pacemaker dependent, which should be considered palliative, end-of-life care, and not physician-assisted suicide. However, any decision is complex, should involve all stakeholders, and will always be patient specific. Top 10 Take Home Messages 10. Identifying patient populations that will benefit the most from emerging pacing technologies (e.g., His bundle pacing, transcatheter leadless pacing systems) will require further investigation as these modalities are incorporated into clinical practice.

2018 Bradycardia Guideline General Evaluation of Patients With Documented or Suspected Bradycardia or Conduction Disorders History and Physical Examination Recommendation for History and Physical Examination in Patients With Documented or Suspected Bradycardia or Conduction Disorders COR I LOE C-EO Recommendation In patients with suspected bradycardia or conduction disorders a comprehensive history and physical examination should be performed. Figure 1. Evaluation of Bradycardia and Conduction Disease Algorithm Patient with symptoms suggestive of or consistent with bradycardia or conduction disorder SND*

SND Diagnostic algorithm Comprehensive history and physical examination (Class I) Sleep apnea? ECG (Class I) Directed blood testing (Class IIa) AV Block AV Block Diagnostic algorithm Conduction disorder with 1:1 AV conduction Nondiagnostic Conduction disorder Diagnostic algorithm Echocardiography if structural heart disease suspected

Exercise-related symptoms Yes Exercise ECG testing (Class IIa) Abnormal No Infrequent Symptoms (>30 days) ICM (Class IIa) Normal Ambulatory ECG monitoring (Class I) Significant arrythmias SND AV Block Conduction disorder with 1:1 AV conduction

SND Diagnostic algorithm AV Block Diagnostic algorithm Conduction disorder Diagnostic algorithm No significant arrhythmias Observation Continued concern for bradycardia? Figure 2. Initial Evaluation of Suspected or Documented SND Algorithm Evidence for sinus node dysfunction* Can we fix this arrow? Reversible or physiologic cause Treat underlying cause as needed, (e.g., sleep apnea (Class I)

Yes Can we make these lines even? No Treatment effective or unnecessary Yes Suspicion for structural heart disease No Observe Yes Transthoracic echocardiography (Class IIa) No Suspicion for infitrative CM, endocarditis, ACHD

Yes Advanced imaging (Class IIa) No Treat identified abnormalities Symptoms Yes No Observe Exercise related Yes No If not already performed: Exercise ECG testing (Class IIa) Diagnostic No Yes If not already performed:

Ambulatory ECG monitoring (Class I) Electrophysiology study (if performed for other reasons) (Class IIb) Sinus node dysfunction treatment algorithm Figure 3. Initial Evaluation of Suspected Atrioventricular Block Algorithm Evidence for AV Block Reversible or Physiologic cause Yes No Treat underlying cause as needed, e.g., sleep apnea (Class I) Treatment effective or not necessary Mobitz type II 2 AV Block, Advanced AV Block,

complete heart block No Yes Observe Yes No Transthoracic echocardiography (Class I) Suspicion for structural heart disease Suspicion for infiltrative CM, endocarditis, ACHD, etc. Yes Suspicion for infiltrative CM, endocarditis, ACHD, etc.

Yes Advanced imaging* (Class IIa) No AV block treatment algorithm Yes Advanced imaging (Class IIa) No No Transthoracic echocardiography (Class IIa) Treat identified abnormalities Infranodal AV node (Mobitz Type I)

Unclear e.g. 2:1 AV Block Symptoms Symptoms Yes AV block treatment algorithm AV block treatment algorithm No Exercise testing (Class IIa) Infranodal Electrophysiology study (Class IIb) Infranodal AV node

Observe AV block treatment algorithm Yes AV block treatment algorithm No Observe Determine site of AV Block Table 4. Medications That Can Induce/Exacerbate Bradycardia or Conduction Disorders Antihypertensive

Beta-adrenergic receptor blockers (including betaadrenergic blocking eye drops used for glaucoma) Clonidine Methyldopa Non-dihydropyridine calcium channel blockers Reserpine Antiarrhythmic Adenosine Amiodarone Dronedarone Flecainide Procainamide Propafenone Quinidine

Sotalol Psychoactive Donepezil Lithium Opioid analgesics Phenothiazine antiemetics and antipsychotics Phenytoin Selective serotonin reuptake inhibitors Tricyclic antidepressants Other

Anesthetic drugs (propofol) Cannabis Digoxin Ivabradine Muscle relaxants (e.g., succinylcholine) Table 5. Conditions Associated With Bradycardia and Conduction Disorders Intrinsic Cardiomyopathy (ischemic or nonischemic) Congenital heart disease Degenerative fibrosis Infection/inflammation Chagas disease Diphtheria Infectious endocarditis Lyme disease Myocarditis Sarcoidosis

Toxoplasmosis Infiltrative disorders Amyloidosis Hemochromatosis Lymphoma Ischemia/infarction Rheumatological conditions Rheumatoid arthritis Scleroderma Systemic lupus erythematosus Surgical or procedural trauma Cardiac procedures such as ablation or cardiac catheterization Congenital heart disease surgery Septal myomectomy for hypertrophic obstructive cardiomyopathy Valve surgery (including percutaneous valve replacement) Extrinsic Autonomic perturbation

Carotid sinus hypersensitivity Neurally-mediated syncope/presyncope Physical conditioning Situational syncope o Cough o Defecation o Glottic stimulation o Medical procedures o Micturition o Vomiting Sleep (with or without sleep apnea) Metabolic Acidosis Hyperkalemia Hypokalemia Hypothermia Hypothyroidism Hypoxia

2018 Bradycardia Guideline Noninvasive Evaluation Resting ECG Recommendation for Electrocardiogram (ECG) in Patients With Documented or Suspected Bradycardia or Conduction Disorders COR I LOE B-NR Recommendation In patients with suspected bradycardia or conduction disorder, a 12-lead ECG is recommended to document rhythm, rate, and conduction, and to screen for structural heart disease or systemic illness. Exercise Electrocardiographic Testing Recommendations for Exercise Electrocardiographic Testing in Patients With Documented or Suspected Bradycardia or Conduction Disorders COR IIa

IIa LOE Recommendation In patients with suspected chronotropic incompetence, exercise electrocardiographic testing is reasonable to B-NR ascertain the diagnosis and provide information on prognosis. C-LD In patients with exercise-related symptoms suspicious for bradycardia or conduction disorders, or in patients with 2:1 atrioventricular block of unknown level, exercise electrocardiographic testing is reasonable. Ambulatory Electrocardiography Recommendation for Ambulatory Electrocardiography in Patients With Documented or Suspected Bradycardia or Conduction Disorders COR I LOE Recommendation B-NR

In the evaluation of patients with documented or suspected bradycardia or conduction disorders, cardiac rhythm monitoring is useful to establish correlation between heart rate or conduction abnormalities with symptoms, with the specific type of cardiac monitor chosen based on the frequency and nature of symptoms, as well as patient preferences. Table 6. Cardiac Rhythm Monitors (adapted) Type of Monitor Patient selection Nonphysician prescribed smartphone-based systems Patient access to the technology Holter monitor Symptoms frequent enough to be detected within a short period (2472 h) of monitoring Patient-activated, transtelephonic Frequent, spontaneous symptoms likely to recur within 26 wk Limited use in patients with incapacitating symptoms monitor (event monitor) External loop recorder (patient or Frequent, spontaneous symptoms potentially related to bradycardia or conduction disorder, likely to recur within 26 wk auto triggered) External patch recorders

Mobile cardiac outpatient telemetry Implantable cardiac monitor Can be considered as an alternative to external loop recorder Given that it is leadless, can be accurately self-applied, and is largely water resistant, it may be more comfortable and less cumbersome than an external loop recorder, potentially improving compliance Unlike Holter monitors and other external monitors, it offers only 1-lead recording Spontaneous symptoms, potentially related to bradycardia or conduction disorder, that are too brief, too subtle, or too infrequent to be readily documented with patient activated monitors In high-risk patients whose rhythm requires real-time monitoring Recurrent, infrequent, unexplained symptoms, potentially related to bradycardia or conduction disorder after a nondiagnostic initial workup, with or without structural heart disease Cardiac Imaging Recommendations for Cardiac Imaging in Bradycardia or Conduction Disorders COR

I IIa LOE B-NR B-NR Recommendation In patients with newly identified LBBB, second-degree Mobitz type II atrioventricular block, high-grade atrioventricular block, or third-degree atrioventricular block with or without apparent structural heart disease or coronary artery disease, transthoracic echocardiography is recommended. In selected patients presenting with bradycardia or conduction disorders other than LBBB, second-degree Mobitz type II atrioventricular block, high-grade atrioventricular block, or thirddegree atrioventricular block, transthoracic echocardiography is reasonable if structural heart disease is suspected. Cardiac Imaging (continued) Recommendations for Cardiac Imaging in Bradycardia or Conduction Disorders COR IIa III: No

Benefit LOE C-LD B-NR Recommendation In selected patients with bradycardia or bundle branch block, disease-specific advanced imaging (e.g., transesophageal echocardiography, computed tomography, cardiac magnetic resonance imaging [MRI], or nuclear imaging) is reasonable if structural heart disease is suspected yet not confirmed by other diagnostic modalities. In the evaluation of patients with asymptomatic sinus bradycardia or first-degree atrioventricular block and no clinical evidence of structural heart disease, routine cardiac imaging is not indicated. Laboratory Testing Recommendation for Laboratory Testing in Patients With Documented or Suspected Bradycardia or Conduction Disorders COR LOE IIa

C-LD Recommendation In patients with bradycardia, laboratory tests (e.g., thyroid function tests, Lyme titer, potassium, pH) based on clinical suspicion for a potential underlying cause are reasonable. Genetic Testing Recommendations for Genetic Testing in Documented or Suspected Bradycardia or Conduction Disorders COR I IIb LOE Recommendation C-EO In patients in whom a conduction disorder-causative mutation has been identified, genetic counseling and mutation-specific genetic testing of first-degree relatives is recommended to identify similarly affected individuals. C-EO In patients with inherited conduction disease, genetic

counseling and targeted testing may be considered to facilitate cascade screening of relatives as part of the diagnostic evaluation. Sleep Apnea Evaluation and Treatment Recommendations for Sleep Apnea Evaluation and Treatment in Patients With Documented or Suspected Bradycardia or Conduction Disorders COR I I IIa LOE B-NR Recommendation In patients with documented or suspected bradycardia or conduction disorder during sleep, screening for symptoms of sleep apnea syndrome is recommended with subsequent confirmatory testing directed by clinical suspicion. B-NR In patients with sleep-related bradycardia or conduction disorder and documented obstructive sleep apnea, treatment directed specifically at the sleep apnea (e.g., continuous positive airway

pressure and weight loss) is recommended. B-NR In patients who have previously received or are being considered for a PPM for bradycardia or conduction disorder, screening for sleep apnea syndrome is reasonable. 2018 Bradycardia Guideline Invasive Testing Implantable Cardiac Monitor Recommendation for Implantable Cardiac Monitor in Patients With Documented or Suspected Bradycardia or Conduction Disorders COR IIa LOE C-LD Recommendation In patients with infrequent symptoms (>30 days between symptoms) suspected to be caused by bradycardia, long-term ambulatory monitoring with an implantable cardiac monitor (ICM) is reasonable if initial noninvasive evaluation is

nondiagnostic. Electrophysiology Study Recommendation for Electrophysiology Study in Patients With Documented or Suspected Bradycardia or Conduction Disorders COR IIb LOE C-LD Recommendation In patients with symptoms suspected to be attributable to bradycardia, an electrophysiology study (EPS) may be considered in selected patients for diagnosis of, and elucidation of bradycardia mechanism, if initial noninvasive evaluation is nondiagnostic. 2018 Bradycardia Guideline Bradycardia Attributable to Sinus Node Dysfunction Figure 4. Acute Bradycardia Algorithm Acute Bradycardia VS, H+P, ECG

Assessment of stability Assess for and treat reversible causes (COR I) Moderate or severe symptoms No Evaluation and observation Yes Atropine* (Class IIa) Type? Calcium channel blocker Drug Toxicity? Yes Beta blocker Digoxin Anti-digoxin Fab

(COR IIa) IV Calcium (COR IIa) No IV Glucagon (COR IIa) High dose Insulin (COR IIa) Continued symptoms? Yes Acute Pacing Algorithm Yes Severe symptoms/ hemodynamically unstable No MI with AV Block? No Beta-agonists (COR IIb)

Yes Continued symptoms? Yes Acute Pacing Algorithm Yes Aminophylline (COR IIb) Acute Management of Reversible Causes of SND Recommendation for Acute Management of Reversible Causes for Bradycardia Attributable to SND COR LOE Recommendation In symptomatic patients presenting with SND, evaluation and treatment of reversible causes is recommended. I C-EO Table 7. Common Potentially Reversible

or Treatable Causes of SND Acute myocardial ischemia or infarction Athletic training Atrial fibrillation Cardiac surgery Valve replacement, maze procedure, coronary artery bypass graft Drugs or toxins* Toluene, organophosphates, tetrodotoxin, cocaine Electrolyte abnormality Hyperkalemia, hypokalemia, hypoglycemia Heart transplant : Acute rejection, chronic rejection, remodeling Hypervagotonia Hypothermia Therapeutic (post-cardiac arrest cooling) or environmental exposure Hypothyroidism Hypovolemic shock Hypoxemia, hypercarbia, acidosis Sleep apnea, respiratory insufficiency (suffocation, drowning, stroke, drug overdose) Infection Lyme disease, legionella, psittacosis, typhoid fever, typhus, listeria, malaria, leptospirosis, Dengue fever, viral hemorrhagic fevers, Guillain-Barre Medications* Beta blockers, non-dihydropyridine calcium channel blockers, digoxin, antiarrhythmic drugs, lithium,

methyldopa, risperidone, cisplatin, interferon *Incomplete list Acute Medical Therapy Recommendations for Atropine and Beta-Agonists for Bradycardia Attributable to SND COR IIa IIb III: Harm LOE Recommendation C-LD In patients with SND associated with symptoms or hemodynamic compromise, atropine is reasonable to increase sinus rate. C-LD C-LD In patients with SND associated with symptoms or hemodynamic compromise who are at low likelihood of coronary ischemia,

isoproterenol, dopamine, dobutamine, or epinephrine may be considered to increase heart rate and improve symptoms. In patients who have undergone heart transplant without evidence for autonomic reinnervation, atropine should not be used to treat sinus bradycardia. Table 8. Acute Medical Management of Bradycardia Attributable to SND or Atrioventricular Block Symptomatic sinus bradycardia or atrioventricular block Atropine 0.5-1 mg IV (may be repeated every 3-5 min to a maximum dose of 3 mg) Dopamine 5 to 20 mcg/kg/min IV, starting at 5 mcg/kg/min and increasing by 5 mcg/kg/min every 2 min Isoproterenol 20-60 mcg IV bolus followed doses of 10-20 mcg, or infusion of 1-20 mcg/min based on heart rate response Epinephrine 2-10 mcg/min IV or 0.1-0.5 mcg/kg/min IV titrated to desired effect Calcium channel blocker overdose 10% calcium chloride 1-2 g IV every 10-20 min or an infusion of 0.2-0.4 mL/kg/h

10% calcium gluconate 3-6 g IV every 10-20 min or an infusion at 0.6-1.2 mL/kg/h Beta-blocker or calcium channel blocker overdose Glucagon 3-10 mg IV with infusion of 3-5 mg/h High dose insulin therapy IV bolus of 1 unit/kg followed by an infusion of 0.5 units/kg/h Digoxin overdose Digoxin antibody fragment Dosage is dependent on amount ingested or known digoxin concentration Table 8. Acute Medical Management with Theophylline or Aminophylline for Bradycardia Attributable to SND or Atrioventricular Block Second- or third-degree atrioventricular block associated with acute inferior MI Aminophylline 250 mg IV bolus Post-heart transplant Aminophylline

6 mg/kg in 100-200 mL of IV fluid over 20-30 min Theophylline 300 mg IV, followed by oral dose of 5-10 mg/kg/d titrated to effect Spinal cord injury Aminophylline 6 mg/kg in 100-200 mL of IV fluid over 20-30 min Theophylline Oral dose of 5-10 mg/kg/d titrated to effect Therapy of Beta Blocker and Calcium Channel Blocker Mediated Bradycardia Attributable to SND or Atrioventricular Block Recommendations for Therapy of Beta Blocker and Calcium Channel Blocker Mediated Bradycardia COR IIa IIa IIa LOE

C-LD C-LD C-LD Recommendation In patients with bradycardia associated with symptoms or hemodynamic compromise because of calcium channel blocker overdose, intravenous calcium is reasonable to increase heart rate and improve symptoms. In patients with bradycardia associated with symptoms or hemodynamic compromise because of beta-blocker or calcium channel blocker overdose, glucagon is reasonable to increase heart rate and improve symptoms. In patients with bradycardia associated with symptoms or hemodynamic compromise because of beta-blocker or calcium channel blocker overdose, high-dose insulin therapy is reasonable to increase heart rate and improve symptoms. Therapy of Digoxin Mediated Bradycardia Attributable to either SND or Atrioventricular Block Recommendations for Therapy of Digoxin Mediated Bradycardia Attributable to SND or Atrioventricular Block COR IIa III: No Benefit

LOE C-LD C-LD Recommendation In patients with bradycardia associated with symptoms or hemodynamic compromise in the setting of digoxin toxicity, digoxin Fab antibody fragment is reasonable to increase heart rate and improve symptoms. In patients with bradycardia associated with symptoms or hemodynamic compromise attributable to digoxin toxicity, dialysis is not recommended for removal of digoxin. Aminophylline or Theophylline for Bradycardia Attributable to SND Recommendations for Theophylline/Aminophylline for Bradycardia Attributable to SND COR IIa IIa LOE C-LD

C-LD Recommendation In post-heart transplant patients, aminophylline or theophylline is reasonable to increase heart rate if clinically indicated. In patients with SND associated with symptoms or hemodynamic compromise in the setting of acute spinal cord injury, aminophylline or theophylline is reasonable to increase heart rate and improve symptoms. Temporary Pacing Recommendations for Temporary Pacing for Bradycardia Attributable to SND COR IIa IIb III: Harm LOE C-LD C-LD C-LD

Recommendation In patients with persistent hemodynamically unstable SND refractory to medical therapy, temporary transvenous pacing is reasonable to increase heart rate and improve symptoms until a PPM is placed or the bradycardia resolves. In patients with SND with severe symptoms or hemodynamic compromise, temporary transcutaneous pacing may be considered to increase heart rate and improve symptoms until a temporary transvenous or PPM is placed or the bradycardia resolves. In patients with SND with minimal and/or infrequent symptoms without hemodynamic compromise, temporary transcutaneous or transvenous pacing should not be performed. Figure 5. Acute Pacing Algorithm Hemodynamic instability despite medical therapy Critically ill due to bradycardia Yes Transcutaneous pacing (Class IIb) No Permanent pacemaker indicated and capability immediately available

Yes Implant Permanent pacemaker* No Prolonged temporary pacing needed Yes Externalized permanent pacing lead (Class IIa) No Temporary transvenous pacing wire (Class IIa) General Principles of Chronic Therapy/Management of Bradycardia due to SND Recommendations for General Principles of Chronic Therapy/Management of Bradycardia Attributable to SND COR III: Harm III:

Harm III: Harm LOE C-LD C-LD C-LD Recommendation In asymptomatic individuals with sinus bradycardia or sinus pauses that are secondary to physiologically elevated parasympathetic tone, permanent pacing should not be performed. In patients with sleep-related sinus bradycardia or transient sinus pauses occurring during sleep, permanent pacing should not be performed unless other indications for pacing are present. In patients with asymptomatic SND, or in those in whom the symptoms have been documented to occur in the absence of bradycardia or chronotropic incompetence, permanent pacing should not be performed. Transient/Reversible Causes (Including Medications) of Sinus Bradycardia Recommendation for Transient/Reversible Causes of Sinus Bradycardia COR

I LOE Recommendation C-EO Patients presenting with symptomatic SND secondary to a reversible cause should first be managed by directing the therapy at eliminating or mitigating the offending condition. Additional Testing in SND Recommendations for Additional Testing of Bradycardia Attributable to SND COR IIb IIb III: No Benefit LOE Recommendation C-EO

In patients with symptoms suggestive of bradycardia (e.g., syncope, lightheadedness) who are also undergoing an EPS for another indication, evaluation of sinus node function as part of the EPS may be considered. C-EO In symptomatic patients with suspected SND, EPS for the assessment of sinus node function may be considered when the diagnosis remains uncertain after initial noninvasive evaluations. In patients with asymptomatic sinus bradycardia, an EPS should not be performed unless other indications for electrophysiological testing exist. C-LD Permanent Pacing for SND Recommendations for Permanent Pacing for Chronic Therapy/Management of Bradycardia Attributable to SND COR I I LOE Recommendation C-LD In patients with symptoms that are directly attributable to SND,

permanent pacing is indicated to increase heart rate and improve symptoms. C-EO In patients who develop symptomatic sinus bradycardia as a consequence of guideline-directed management and therapy for which there is no alternative treatment and continued treatment is clinically necessary, permanent pacing is recommended to increase heart rate and improve symptoms. Permanent Pacing for SND (continued) Recommendations for Permanent Pacing for Chronic Therapy/Management of Bradycardia Attributable to SND COR IIa IIa IIb LOE C-EO C-EO C-LD

Recommendation For patients with tachy-brady syndrome and symptoms attributable to bradycardia, permanent pacing is reasonable to increase heart rate and reduce symptoms attributable to hypoperfusion. In patients with symptomatic chronotropic incompetence, permanent pacing with rate-responsive programming is reasonable to increase exertional heart rates and improve symptoms. In patients with symptoms that are likely attributable to SND, a trial of oral theophylline may be considered to increase heart rate, improve symptoms, and help determine the potential effects of permanent pacing. Permanent Pacing Techniques and Methods for Chronic Therapy/Management of SND Recommendations for Permanent Pacing Techniques and Methods for Chronic Therapy/Management of Bradycardia Attributable to SND COR I I LOE B-R B-R Recommendation In symptomatic patients with SND, atrial-based pacing is

recommended over single chamber ventricular pacing. In symptomatic patients with SND and intact atrioventricular conduction without evidence of conduction abnormalities, dual chamber or single chamber atrial pacing is recommended. Permanent Pacing Techniques and Methods for Chronic Therapy/Management of SND Recommendations for Permanent Pacing Techniques and Methods for Chronic Therapy/Management of Bradycardia Attributable to SND COR IIa IIa LOE Recommendation B-R In symptomatic patients with SND who have dual chamber pacemakers and intact atrioventricular conduction, it is reasonable to program the dual chamber pacemaker to minimize ventricular pacing. C-EO In symptomatic patients with SND in which frequent ventricular pacing is not expected or the patient has significant comorbidities

that are otherwise likely to determine the survival and clinical outcomes, single chamber ventricular pacing is reasonable. Figure 6. Chronic SND Management Algorithm Sinus node dysfunction Confirm symptoms Rule out reversible causes Due to required GDMT (no reasonable alternative) Symptoms correlate with bradycardia No Yes Yes No (or asymptomatic) Likely/uncertain Observation Permanent pacing (Class I) Oral theophylline

(Class IIb) Infrequent pacing? Significant comorbidities? Response suggests symptomatic sinus node dysfunction? Yes Single chamber ventricular pacing (Class IIa) No Yes Permanent pacing (Class III: Harm) No Willing to have a PPM? Normal AV conduction and reason to

avoid an RV lead? Yes Single chamber atrial pacing (Class I) Yes No Dual chamber pacing (Class I) Program to minimize ventricular pacing (Class IIa) No Oral theophylline (Class IIb) 2018 Bradycardia Guideline Bradycardia Attributable to Atrioventricular Block Table 9. Etiology of Atrioventricular Block Congenital/genetic Congenital AV block (associated with maternal

systemic lupus erythematosus) Congenital heart defects (e.g., L-TGA) Genetic (e.g., SCN5A mutations) Vagotonic-associated with increased vagal tone Sleep, obstructive sleep apnea High-level athletic conditioning Neurocardiogenic Infectious Lyme carditis Bacterial endocarditis with perivalvar abscess Acute rheumatic fever Chagas disease Toxoplasmosis Metabolic/endocrine Acid-base disorders

Poisoning/overdose (e.g., mercury, cyanide, carbon monoxide, mad honey) Thyroid disease (both hypothyroidism and hyperthyroidism) Adrenal disease (e.g., pheochromocytoma, hypoaldosteronism) Inflammatory/infiltrative Other diseases Myocarditis Neuromuscular diseases (e.g., myotonic dystrophy, Amyloidosis Kearns-Sayre syndrome, Erbs dystrophy) Cardiac sarcoidosis Lymphoma Rheumatologic disease: Systemic sclerosis, SLE, RA, reactive arthritis (Reiters syndrome) Other cardiomyopathy-idiopathic, valvular Ischemic Acute MI

Coronary ischemia without infarctionunstable angina, variant angina Chronic ischemic cardiomyopathy Degenerative Levs and Lenegres diseases Iatrogenic Medication related o Beta blockers, verapamil, diltiazem, digoxin o Antiarrhythmic drugs o Neutraceuticals Catheter ablation Cardiac surgery, especially valve surgery TAVR, alcohol septal ablation Acute Management of Reversible Causes of Atrioventricular Block Recommendations for Acute Management of Reversible Causes of Bradycardia Attributable to Atrioventricular Block COR LOE

I B-NR IIa B-NR Recommendation Patients with transient or reversible causes of atrioventricular block, such as Lyme carditis or drug toxicity, should have medical therapy and supportive care, including temporary transvenous pacing if necessary, before determination of need for permanent pacing. In selected patients with symptomatic second-degree or thirddegree atrioventricular block who are on chronic stable doses of medically necessary antiarrhythmic or beta-blocker therapy, it is reasonable to proceed to permanent pacing without further observation for drug washout or reversibility. Acute Management of Reversible Causes of Atrioventricular Block Recommendations for Acute Management of Reversible Causes of Bradycardia Attributable to Atrioventricular Block COR IIa IIb LOE

B-NR C-LD Recommendation In patients with second-degree or third-degree atrioventricular block associated with cardiac sarcoidosis, permanent pacing, with additional defibrillator capability if needed and meaningful survival of greater than 1 year is expected, without further observation for reversibility is reasonable. In patients with symptomatic second-degree or third-degree atrioventricular block associated with thyroid function abnormalities but without clinical myxedema, permanent pacing without further observation for reversibility may be considered. Acute Medical Therapy of Atrioventricular Block Recommendations for Acute Medical Therapy for Bradycardia Attributable to Atrioventricular Block COR IIa IIb IIb LOE Recommendation

C-LD For patients with second-degree or third-degree atrioventricular block believed to be at the atrioventricular nodal level associated with symptoms or hemodynamic compromise, atropine is reasonable to improve atrioventricular conduction, increase ventricular rate, and improve symptoms. B-NR C-LD For patients with second-degree or third-degree atrioventricular block associated with symptoms or hemodynamic compromise and who have low likelihood for coronary ischemia, beta-adrenergic agonists, such as isoproterenol, dopamine, dobutamine, or epinephrine, may be considered to improve atrioventricular conduction, increase ventricular rate, and improve symptoms. For patients with second-degree or third-degree atrioventricular block associated with symptoms or hemodynamic compromise in the setting of acute inferior MI, intravenous aminophylline may be considered to improve atrioventricular conduction, increase ventricular rate, and improve symptoms. Temporary Pacing for Atrioventricular Block Recommendations for Temporary Pacing for Bradycardia Attributable to Atrioventricular Block COR IIa IIa

IIb LOE Recommendation B-NR For patients with second-degree or third-degree atrioventricular block associated with symptoms or hemodynamic compromise that is refractory to medical therapy, temporary transvenous pacing is reasonable to increase heart rate and improve symptoms. B-NR For patients who require prolonged temporary transvenous pacing, it is reasonable to choose an externalized permanent active fixation lead over a standard passive fixation temporary pacing lead. B-R For patients with second-degree or third-degree atrioventricular block and hemodynamic compromise refractory to antibradycardic medical therapy, temporary transcutaneous pacing may be considered until a temporary transvenous or PPM is placed or the bradyarrhythmia resolves. Figure 7. Management of Bradycardia or Pauses Attributable to Chronic Atrioventricular Block Algorithm AV Block

Mobitz Type I block Marked first degree AV Block Symptoms* Yes Symptoms* No Yes La min A/C, Neuromuscular disease Yes Neuromuscular disease Permanent pa cing (Class IIa) No Complete Heart Block (acquired),

Advanced AV Block, Mobitz Type II, Evidence for Infranodal Block Lamin A/C No Neuromuscular disease associated with progre ssive conduction tissue disorder No Yes Observation No Observation Yes Yes Permanent pacing

(Class IIb ) Permanen t pacing (Class IIa) Permanent pacing (Class III: Harm) Permanent pacing (Class IIa) Permanent pacing (Class I) Permanent pacing (Class III : Harm) Consider risk of ventricular arrhythmia (Class I) Cardiac resynchronization therapy candidate because of HF symptoms? (LVEF <35%)

Yes No GDMT Infrequent pacing? Significant comorbidities? No Yes Single chamber ventricular pacing (Class I) Yes Single chamber ventricular pacing (Class I) Permanent atrial fibrillation? No Dual cha mber pacin g (Class I) No LVEF >50% No

Yes Right ventricular pacing lead (Class IIa) Predicted pacing <40%? Yes No Pacing to maintain physiologic left ventricular activation (Class IIa) His bundle pacing (Class IIb) Right ventricular pacing lead (Class IIa) Permanent pacing (Class I) General Principles of Chronic Therapy/Management of Atrioventricular Block Recommendations for General Principles of Chronic Therapy/Management of Bradycardia Attributable to Atrioventricular Block COR III:

Harm III: Harm LOE C-LD C-LD Recommendation In patients with first-degree atrioventricular block or seconddegree Mobitz type I (Wenckebach) or 2:1 atrioventricular block which is believed to be at the level of the atrioventricular node, with symptoms that do not temporally correspond to the atrioventricular block, permanent pacing should not be performed. In asymptomatic patients with first-degree atrioventricular block or second-degree Mobitz type I (Wenckebach) or 2:1 atrioventricular block which is believed to be at the level of the atrioventricular node, permanent pacing should not be performed. Transient/Potentially Reversible Causes of Atrioventricular Block Recommendations for Potentially Reversible or Transient Causes of Atrioventricular Block COR I

III: Harm III: Harm LOE C-LD C-LD C-LD Recommendation In patients with symptomatic atrioventricular block attributable to a known reversible cause in whom the atrioventricular block does not resolve despite treatment of the underlying cause, permanent pacing is recommended. In patients who had acute atrioventricular block attributable to a known reversible and nonrecurrent cause and have had complete resolution of the atrioventricular block with treatment of the underlying cause, permanent pacing should not be performed. In patients with asymptomatic vagally mediated atrioventricular block, permanent pacing should not be performed. Additional Testing for Chronic Therapy/Management of Atrioventricular Block Recommendations for Additional Testing for Chronic Therapy/Management of Bradycardia Attributable to Atrioventricular Block

COR IIa IIa LOE B-R C-LD Recommendation In patients with symptoms (e.g., lightheadedness, dizziness) of unclear etiology who have first-degree atrioventricular block or second-degree Mobitz type I atrioventricular block on ECG, ambulatory electrocardiographic monitoring is reasonable to establish correlation between symptoms and rhythm abnormalities. In patients with exertional symptoms (e.g., chest pain, shortness of breath) who have first-degree or second-degree Mobitz type I atrioventricular block at rest, an exercise treadmill test is reasonable to determine whether they may benefit from permanent pacing. Additional Testing for Chronic Therapy/Management of Atrioventricular Block (continued) Recommendations for Additional Testing for Chronic Therapy/Management of Bradycardia Attributable to Atrioventricular Block

COR IIb IIb LOE Recommendation In selected patients with second-degree atrioventricular block, an EPS may be considered to determine the level of B-NR the block and to determine whether they may benefit from permanent pacing. C-LD In selected patients with second-degree atrioventricular block, carotid sinus massage and/or pharmacological challenge with atropine, isoproterenol, or procainamide may be considered to determine the level of the block and to determine whether they may benefit from permanent pacing. Permanent Pacing for Atrioventricular Block Recommendations for Permanent Pacing for Chronic Therapy/Management of Bradycardia Attributable to Atrioventricular Block COR I I

LOE B-NR B-NR Recommendation In patients with acquired second-degree Mobitz type II atrioventricular block, high-grade atrioventricular block, or thirddegree atrioventricular block not attributable to reversible or physiologic causes, permanent pacing is recommended regardless of symptoms. In patients with neuromuscular diseases associated with conduction disorders, including muscular dystrophy (e.g., myotonic dystrophy type 1) or Kearns-Sayre syndrome, who have evidence of second-degree atrioventricular block, third-degree atrioventricular block, or an HV interval of 70 ms or greater, regardless of symptoms, permanent pacing, with additional defibrillator capability if needed and meaningful survival of greater than 1 year is expected, is recommended. Permanent Pacing for Atrioventricular Block (continued) Recommendations for Permanent Pacing for Chronic Therapy/Management of Bradycardia Attributable to Atrioventricular Block COR I I

LOE C-LD C-LD Recommendation In patients with permanent AF and symptomatic bradycardia, permanent pacing is recommended. In patients who develop symptomatic atrioventricular block as a consequence of guideline-directed management and therapy for which there is no alternative treatment and continued treatment is clinically necessary, permanent pacing is recommended to increase heart rate and improve symptoms. Permanent Pacing for Atrioventricular Block (continued) Recommendations for Permanent Pacing for Chronic Therapy/Management of Bradycardia Attributable to Atrioventricular Block COR IIa IIa LOE B-NR B-NR

Recommendation In patients with an infiltrative cardiomyopathy, such as cardiac sarcoidosis or amyloidosis, and second-degree Mobitz type II atrioventricular block, high-grade atrioventricular block, or thirddegree atrioventricular block, permanent pacing, with additional defibrillator capability if needed and meaningful survival of greater than 1 year is expected, is reasonable. In patients with lamin A/C gene mutations, including limb-girdle and Emery Dreifuss muscular dystrophies, with a PR interval greater than 240 ms and LBBB, permanent pacing, with additional defibrillator capability if needed and meaningful survival of greater than 1 year is expected, is reasonable. Permanent Pacing for Atrioventricular Block (continued) Recommendations for Permanent Pacing for Chronic Therapy/Management of Bradycardia Attributable to Atrioventricular Block COR IIa IIb LOE C-LD C-LD Recommendation In patients with marked first-degree or second-degree Mobitz

type I (Wenckebach) atrioventricular block with symptoms that are clearly attributable to the atrioventricular block, permanent pacing is reasonable. In patients with neuromuscular diseases, such as myotonic dystrophy type 1, with a PR interval greater than 240 ms, a QRS duration greater than 120 ms, or fascicular block, permanent pacing, with additional defibrillator capability if needed and meaningful survival of greater than 1 year is expected, may be considered. Permanent Pacing Techniques and Methods for Chronic Therapy/Management of Atrioventricular Block Recommendations for Permanent Pacing Techniques and Methods for Chronic Therapy/Management of Bradycardia Attributable to Atrioventricular Block COR I I LOE A A Recommendation In patients with SND and atrioventricular block who require permanent pacing, dual chamber pacing is recommended over

single chamber ventricular pacing. In select patients with atrioventricular block who require permanent pacing in whom frequent ventricular pacing is not expected, or who have significant comorbidities that are likely to determine clinical outcomes and that may limit the benefit of dual chamber pacing, single chamber ventricular pacing is effective. Permanent Pacing Techniques and Methods for Chronic Therapy/Management of Atrioventricular Block (continued) Recommendations for Permanent Pacing Techniques and Methods for Chronic Therapy/Management of Bradycardia Attributable to Atrioventricular Block COR I IIa LOE Recommendation B-R For patients in sinus rhythm with a single chamber ventricular pacemaker who develop pacemaker syndrome, revising to a dual chamber pacemaker is recommended. B-RSR

In patients with atrioventricular block who have an indication for permanent pacing with a LVEF between 36% and 50% and are expected to require ventricular pacing more than 40% of the time, it is reasonable to choose pacing methods that maintain physiologic ventricular activation (e.g., cardiac resynchronization therapy [CRT] or His bundle pacing) over right ventricular pacing. Permanent Pacing Techniques and Methods for Chronic Therapy/Management of Atrioventricular Block (continued) Recommendations for Permanent Pacing Techniques and Methods for Chronic Therapy/Management of Bradycardia Attributable to Atrioventricular Block COR IIa IIb III: Harm LOE B-R Recommendation In patients with atrioventricular block who have an indication for permanent pacing with a LVEF between 36% and 50% and are expected to require ventricular pacing less than 40% of the time, it is reasonable to choose right ventricular pacing over pacing methods that maintain

physiologic ventricular activation (e.g., CRT or His bundle pacing). B-RSR In patients with atrioventricular block at the level of the atrioventricular node who have an indication for permanent pacing, His bundle pacing may be considered to maintain physiologic ventricular activation. C-LD In patients with permanent or persistent AF in whom a rhythm control strategy is not planned, implantation of an atrial lead should not be performed. 2018 Bradycardia Guideline Conduction Disorders (With 1:1 Atrioventricular Conduction) Evaluation of Conduction Disorders Recommendations for Evaluation of Conduction Disorders (With 1:1 Atrioventricular Conduction and Normal PR Interval) COR I I LOE

Recommendation B-NR In patients with newly detected LBBB, a transthoracic echocardiogram to exclude structural heart disease is recommended. C-LD In symptomatic patients with conduction system disease, in whom atrioventricular block is suspected, ambulatory electrocardiographic monitoring is useful. Evaluation of Conduction Disorders (continued) Recommendations for Evaluation of Conduction Disorders (With 1:1 Atrioventricular Conduction and Normal PR Interval) COR IIa IIa LOE B-NR B-NR Recommendation

In selected patients presenting with intraventricular conduction disorders other than LBBB, transthoracic echocardiography is reasonable if structural heart disease is suspected. In patients with symptoms suggestive of intermittent bradycardia (e.g., lightheadedness, syncope), with conduction system disease identified by ECG and no demonstrated atrioventricular block, an EPS is reasonable. Evaluation of Conduction Disorders (continued) Recommendations for Evaluation of Conduction Disorders (With 1:1 Atrioventricular Conduction and Normal PR Interval) COR IIa IIb IIb LOE C-LD Recommendation In selected patients with LBBB in whom structural heart disease is suspected and echocardiogram is unrevealing, advanced imaging (e.g., cardiac MRI, computed tomography, or nuclear studies) is reasonable. C-LD

In selected asymptomatic patients with extensive conduction system disease (bifascicular or trifascicular block), ambulatory electrocardiographic recording may be considered to document suspected higher degree of atrioventricular block. C-LD In selected asymptomatic patients with LBBB in whom ischemic heart disease is suspected, stress testing with imaging may be considered. Figure 8. Evaluation of Conduction Disorders Algorithm Evidence for conduction disorder Reversible or Physiologic cause Yes Treat underlying cause as needed, e.g., ischemia No Treatment effective or not necessary Yes

Observe No Genetic disorder associated with conduction disease Yes Conduction disorders treatment algorithm* Advanced imaging (Class IIb) No Suspicion for infiltrative CM, endocarditis, ACHD, etc. Yes No Type of conduction disorder LBBB

RBBB or fascicular block Transthoracic echocardiography (Class I) Transthoracic echocardiography (Class IIa) Treat identified abnormalities Symptoms suggestive of intermittent bradycardia Yes No Ambulatory ECG Monitoring (Class I) Ambulatory ECG Monitoring (Class IIb) Electrophysiology study (Class IIa)

Observe Management of Conduction Disorders (With 1:1 Atrioventricular Conduction) Recommendations for Management of Conduction Disorders (With 1:1 Atrioventricular Conduction and Normal PR Intervals) COR I I LOE Recommendation C-LD In patients with syncope and bundle branch block who are found to have an HV interval 70 ms or greater or evidence of infranodal block at EPS, permanent pacing is recommended. C-LD In patients with alternating bundle branch block, permanent pacing is recommended. Management of Conduction Disorders (With 1:1 Atrioventricular Conduction) (continued) Recommendations for Management of Conduction Disorders (With 1:1

Atrioventricular Conduction and Normal PR Intervals) COR IIa IIb LOE Recommendation C-LD In patients with Kearns-Sayre syndrome and conduction disorders, permanent pacing is reasonable, with additional defibrillator capability if appropriate and meaningful survival of greater than 1 year is expected. C-LD In patients with Anderson-Fabry disease and QRS prolongation greater than 110 ms, permanent pacing, with additional defibrillator capability if needed and meaningful survival of greater than 1 year is expected, may be considered. Management of Conduction Disorders (With 1:1 Atrioventricular Conduction) (continued) Recommendations for Management of Conduction Disorders (With 1:1 Atrioventricular Conduction and Normal PR Intervals) COR

IIb III: Harm LOE C-LD B-NR Recommendation In patients with heart failure, a mildly to moderately reduced LVEF (36%-50%), and LBBB (QRS 150 ms), CRT may be considered. In asymptomatic patients with isolated conduction disease and 1:1 atrioventricular conduction, permanent pacing is not indicated (in the absence of other indications for pacing). Figure 9. Management of Conduction Disorders Algorithm Conduction disorder: BBB or fascicular block with 1:1 AV conduction* Syncope, BBB, and HV >70ms No

Yes Permanent pacing (Class I) Yes Permanent pacing (Class I) Alternating BBB No LVEF 36-50%, LBBB, QRS >150 ms, and Class II or greater HF symptoms Yes No Symptoms suggest intermittent AV block? Yes AV block diagnostic algorithm No Observation

Cardiac resynchronization therapy (Class IIb) 2018 Bradycardia Guideline Special Populations Patients at Risk for Bradycardia During Noncardiac Surgery or Procedures Recommendations for Patients at Risk for Bradycardia During Noncardiac Surgery or Procedures COR IIa III: Harm LOE B-NR B-NR Recommendation In patients who are thought to be at high risk for the development of intraoperative or periprocedural bradycardia because of patient characteristics or procedure type, placement of transcutaneous pacing pads is reasonable.

In patients with LBBB who require pulmonary artery catheterization for intraoperative monitoring, routine prophylactic temporary transvenous pacing should not be performed. Coronary Artery Bypass Surgery Recommendations for Pacing After Isolated Coronary Artery Bypass Surgery COR I IIa IIb LOE B-NR B-NR C-EO Recommendation In patients who have new postoperative SND or atrioventricular block associated with persistent symptoms or hemodynamic instability that does not resolve after isolated coronary artery bypass surgery, permanent pacing is recommended before discharge. In patients undergoing isolated coronary artery bypass surgery,

routine placement of temporary epicardial pacing wires is reasonable. In patients undergoing coronary artery bypass surgery who will likely require future CRT or ventricular pacing, intraoperative placement of a permanent epicardial left ventricular lead may be considered. Surgery for Atrial Fibrillation Recommendations for Pacing After Surgery for Atrial Fibrillation COR I I IIb LOE B-NR B-NR C-EO Recommendation In patients undergoing surgery for AF, routine placement of temporary epicardial pacing wires is recommended. In patients who have new postoperative SND or atrioventricular block associated with symptoms or hemodynamic instability that does not resolve after surgery for AF, permanent pacing is

recommended before discharge. In patients undergoing surgery for AF who will likely require future CRT or ventricular pacing, intraoperative placement of a permanent epicardial left ventricular lead may be considered. Surgical Aortic Valve Replacement or Repair Recommendations for Pacing After Aortic Valve Surgery COR I I IIb LOE Recommendation C-LD In patients undergoing surgical aortic valve replacement or repair, routine placement of temporary epicardial pacing wires is recommended. B-NR C-EO In patients who have new postoperative SND or atrioventricular

block associated with persistent symptoms or hemodynamic instability that does not resolve after aortic valve replacement, permanent pacing is recommended before discharge. In patients undergoing aortic valve surgery who will likely require future CRT or ventricular pacing, intraoperative placement of a permanent epicardial left ventricular lead may be considered. Mitral Valve Surgery Recommendations for Pacing After Mitral Valve Surgery COR I IIa IIb LOE B-NR Recommendation In patients who have new postoperative SND or atrioventricular block associated with persistent symptoms or hemodynamic instability that does not resolve after mitral valve repair or replacement surgery, permanent pacing is recommended before discharge. C-LD

In patients undergoing mitral valve surgery, routine placement of temporary epicardial pacing wires is reasonable. C-EO In patients undergoing surgical mitral valve repair or replacement who will likely require future CRT or ventricular pacing, intraoperative placement of a permanent epicardial left ventricular lead may be considered. Tricuspid Valve Surgery Recommendations for Pacing After Tricuspid Valve Surgery COR I I IIa LOE Recommendation C-LD In patients undergoing tricuspid valve surgery, routine placement of temporary epicardial pacing wires is recommended.

B-NR C-LD In patients who have new postoperative SND or atrioventricular block associated with symptoms or hemodynamic instability that does not resolve after tricuspid valve surgery, permanent pacing is recommended before discharge. In patients who are undergoing tricuspid valve replacement or tricuspid repair with high risk for postoperative atrioventricular block, intraoperative placement of permanent epicardial leads at the time of cardiac surgery is reasonable. Transcatheter Aortic Valve Replacement Recommendations for Conduction Disturbances After Transcatheter Aortic Valve Replacement COR I LOE Recommendation In patients who have new atrioventricular block after transcatheter aortic valve replacement associated with symptoms or hemodynamic instability that does not B-NR resolve, permanent pacing is recommended before discharge.

IIa In patients with new persistent bundle branch block after transcatheter aortic valve replacement, careful B-NR surveillance for bradycardia is reasonable. IIb In patients with new persistent LBBB after transcatheter aortic valve replacement, implantation of a PPM may be B-NR considered. Surgical Myectomy and Alcohol Septal Ablation for Hypertrophic Cardiomyopathy Recommendations for Patients Undergoing Surgical Myectomy or Alcohol Septal Ablation for Hypertrophic Cardiomyopathy COR LOE I B-NR IIa B-NR Recommendation

In patients with second-degree Mobitz type II atrioventricular block, high-grade atrioventricular block, or persistent complete atrioventricular block after alcohol septal ablation or surgical myectomy, permanent pacing is recommended before discharge. In selected patients with hypertrophic cardiomyopathy who require permanent pacing for rate support after alcohol septal ablation or surgical myectomy and are at high risk for sudden cardiac death and meaningful survival of greater than 1 year is expected, selecting a device with defibrillator capabilities is reasonable. Surgical Myectomy and Alcohol Septal Ablation for Hypertrophic Cardiomyopathy (continued) Recommendations for Patients Undergoing Surgical Myectomy or Alcohol Septal Ablation for Hypertrophic Cardiomyopathy COR IIb IIb LOE C-LD C-LD Recommendation In patients with hypertrophic cardiomyopathy who undergo alcohol septal ablation and who are at risk for developing late

atrioventricular block, prolonged ambulatory electrocardiographic monitoring may be considered. In patients with hypertrophic cardiomyopathy, evaluation of ventriculoatrial conduction by EPS at the time of alcohol septal ablation may be considered for identifying future risk of atrioventricular block. Bradycardia Management for Adult Congenital Heart Disease Recommendations for Management of Bradycardia in Adults With Adult Congenital Heart Disease COR I I LOE B-NR B-NR Recommendation In adults with adult congenital heart disease (ACHD) and symptomatic SND or chronotropic incompetence, atrial based permanent pacing is recommended. In adults with ACHD and symptomatic bradycardia related to atrioventricular block, permanent pacing is recommended.

Bradycardia Management for Adult Congenital Heart Disease (continued) Recommendations for Management of Bradycardia in Adults With Adult Congenital Heart Disease COR I I LOE B-NR B-NR Recommendation In adults with congenital complete atrioventricular block with any symptomatic bradycardia, a wide QRS escape rhythm, mean daytime heart rate below 50 bpm, complex ventricular ectopy, or ventricular dysfunction, permanent pacing is recommended. In adults with ACHD and postoperative second-degree Mobitz type II atrioventricular block, high-grade atrioventricular block, or third-degree atrioventricular block that is not expected to resolve, permanent pacing is recommended. Bradycardia Management for Adult Congenital Heart Disease (continued) Recommendations for Management of Bradycardia in Adults With Adult Congenital Heart Disease

COR IIa IIa LOE Recommendation In asymptomatic adults with congenital complete B-NR atrioventricular block, permanent pacing is reasonable. In adults with repaired ACHD who require permanent pacing for bradycardic indications, a bradycardia device B-NR with atrial antitachycardia pacing capabilities is reasonable. Bradycardia Management for Adult Congenital Heart Disease (continued) Recommendations for Management of Bradycardia in Adults With Adult Congenital Heart Disease COR IIa IIb III: Harm LOE C-EO

Recommendation In adults with ACHD with preexisting sinus node and/or atrioventricular conduction disease who are undergoing cardiac surgery, intraoperative placement of epicardial permanent pacing leads is reasonable. B-NR In adults with ACHD and pacemakers, atrial-based permanent pacing for the prevention of atrial arrhythmias may be considered. B-NR In selected adults with ACHD and venous to systemic intracardiac shunts, placement of endocardial pacing leads is potentially harmful. Management of Bradycardia in Patients With an Acute MI Recommendations for Management of Bradycardia in the Context of Acute MI COR I I I

LOE B-NR B-NR B-NR Recommendation In patients presenting with an acute MI, temporary pacing is indicated for medically refractory symptomatic or hemodynamically significant bradycardia related to SND or atrioventricular block. Patients who present with SND or atrioventricular block in the setting of an acute MI should undergo a waiting period before determining the need for permanent pacing. In patients presenting with an acute MI with second-degree Mobitz type II atrioventricular block, high-grade atrioventricular block, alternating bundle-branch block, or third-degree atrioventricular block (persistent or infranodal), permanent pacing is indicated after a waiting period. Management of Bradycardia in Patients With an Acute MI (continued) Recommendations for Management of Bradycardia in the Context of Acute MI COR IIa III:

Harm III: Harm LOE Recommendation B-NR In patients with an acute MI with symptomatic or hemodynamically significant sinus bradycardia or atrioventricular block at the level of the atrioventricular node, the administration of atropine is reasonable. B-NR B-NR In patients with an acute MI and transient atrioventricular block that resolves, permanent pacing should not be performed. In patients with an acute MI and a new bundle-branch block or isolated fascicular block in the absence of second-degree or thirddegree atrioventricular block, permanent pacing should not be performed. Epilepsy Recommendation for Patients With Epilepsy and Symptomatic Bradycardia COR

IIa LOE C-LD Recommendation In patients with epilepsy associated with severe symptomatic bradycardia (ictal bradycardia) where antiepileptic medications are ineffective, permanent pacing is reasonable for reducing the severity of symptoms. 2018 Bradycardia Guideline Evaluation of the Risks for Ventricular Arrhythmias in Patients Who Require Permanent Pacing Evaluation of the Risks for Ventricular Arrhythmias in Patients Who Require Permanent Pacing Recommendation for Management of Bradycardia and Conduction Tissue Disease in Patients Who Require Pacing Therapy and May Also Be at Risk for Ventricular Arrhythmias COR I

LOE Recommendation In patients who require permanent pacing therapy, before implantation, an assessment of the risk of future ventricular arrhythmias and need for an ICD should be B-NR performed. 2018 Bradycardia Guideline Shared Decision-Making Shared Decision-Making Recommendations for Shared Decision-Making for Pacemaker Implantation in the Setting of Guideline-Based Indications for Bradycardia Pacing COR LOE I C-LD I III: No Benefit C-LD

C-LD Recommendation In patients with symptomatic bradycardia or conduction disorder, clinicians and patients should engage in a shared decision-making approach in which treatment decisions are based not only on the best available evidence, but also on the patients goals of care, preferences, and values. Patients considering implantation of a pacemaker or with a pacemaker that requires lead revision or generator change should be informed of procedural benefits and risks, including the potential short and long-term complications and possible alternative therapy, if any, in light of their goals of care, preferences, and values. In patients with indications for permanent pacing but also with significant comorbidities such that pacing therapy is unlikely to provide meaningful clinical benefit, or if patient goals of care strongly preclude pacemaker therapy, implantation or replacement of a pacemaker should not be performed. 2018 Bradycardia Guideline Discontinuation of Pacemaker Therapy Discontinuation of Pacemaker Therapy Recommendation for Discontinuation of Pacemaker Therapy COR

IIa LOE C-LD Recommendation 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. 2018 Bradycardia Guideline Knowledge Gaps and Future Research 2018 Bradycardia Guideline His bundle pacing is an emerging area of interest and is particularly relevant in patients who require significant amounts of ventricular pacing, but the long-term outcomes for this approach in large populations of patients remain uncertain (S15-1, S15-2). Although cardiac resynchronization pacing is associated with improvement in outcomes among patients with atrioventricular block and heart failure in general (S15-5, S15-6), the role of cardiac resynchronization in the subgroup of patients with an LVEF of >35% remains

incompletely understood. The relative merits of His bundle pacing, cardiac resynchronization, or other pacing strategies for maintaining or improving left ventricular function in patients with atrioventricular block is unknown. 2018 Bradycardia Guideline The role of pacing among patients with transient bradycardia with reflex-mediated syncope beyond those with documented transient asystole is uncertain (S15-3, S15-4). Pacing with entirely leadless devices is an emerging area of interest (S15-7, S15-8), but the roles of these new devices in real-world practice, and their potential interaction with other cardiac devices is not yet clear. Regardless of technology, for the foreseeable future, pacing therapy requires implantation of a medical device and future studies will be required to focus on the long-term implications associated with lifelong therapy.

Recently Viewed Presentations

  • Morphosyntactic Description and Analysis of English

    Morphosyntactic Description and Analysis of English

    Ambiguous Embedded Phrases. Noun Phrases can also be embedded in Noun Phrases: ... Examples: PPs as modifiers. 2. At the bottom of the rainbow is a pot of gold. ... C. pronoun. D. adverb. E. preposition. review.
  • 1 eRHIC Design and Development eRHIC design goals

    1 eRHIC Design and Development eRHIC design goals

    eRHIC DesignExploiting the RHIC Heavy Ion collider with - its superconducting magnets for up to 250 GeV proton beams- its large accelerator tunnel and its long straight sections- its existing Hadron injector complexby adding an electron accelerator of 18 GeV...
  • Grand Canyon- 36 James Hutton 60 Charles Lyell

    Grand Canyon- 36 James Hutton 60 Charles Lyell

    Grand Canyon- 36 James Hutton 60 Charles Lyell 69 Geologic column 77 Index fossils- 111 Polystrata trees 136 Darwin 183 Variations 218 Moon-green cheese 254
  • European RMM - Fitac

    European RMM - Fitac

    IATA was founded the next year with a focus on working with ICAO to setup international standards for aviation. In the early days, IATA played an important role in facilitating fare setting and in establishing settlement systems for interline networks....
  • Why volunteers shouldn&#x27;t worry (too ... - ANU College of Law

    Why volunteers shouldn't worry (too ... - ANU College of Law

    Different problems lead to different solutions. Rural Fires Association (2010)"...our clear policy on this is that where an individual firefighter or a group of firefighters acts in good faith in carrying out their duties, regardless of outcome they must have...
  • Happy New Year!

    Happy New Year!

    Happy New Year! Chinese New Year How do we celebrate the New Year in U.S? Foods we eat? Activities? How long does it last? Origins of Chinese New Year History Channel History of the Holidays: Chinese New Year Video Questions...
  • 3 IMPORTANT THINGS TO NOTE: A. Joshua had

    3 IMPORTANT THINGS TO NOTE: A. Joshua had

    6 WAYS TO MEDITATE 1. PICTURE it 2. PRONOUNCE it 3. PARAPHRASE it 4. PERSONALIZE it 5. PRAY it 6. PROBE it Visualize the scene in your mind Say it aloud, emphasizing a different word Rewrite the verse in your...
  • Sigma Analysis &amp; Management Ltd.

    Sigma Analysis & Management Ltd.

    Sigma Analysis & Management Ltd. is a Toronto-based firm with operational excellence, world-class hedge fund research with an elite quant group, that delivers high-touch, value-add customized service in the hedge fund space.