File Name: clinical cardiac pacing defibrillation and resynchronization therapy .zip
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The ESC Guidelines represent the views of the ESC and were arrived at after careful consideration of the available evidence at the time they were written. Health professionals are encouraged to take them fully into account when exercising their clinical judgement. The guidelines do not, however, override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patients, in consultation with that patient and, where appropriate and necessary, the patient's guardian or carer.
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The Guidelines do not, however, override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patients, in consultation with that patient and, where appropriate and necessary, the patient's guardian or carer. The prevalence of bradyarrhythmias requiring permanent cardiac pacing therapy is unknown, but an approximation can be obtained from the analysis of some large databases.
Inevitably, knowledge of the natural history of severe bradyarrhythmias comes from very old studies performed at the beginning of the PM era.
In some situations, efficacy of pacing is therefore inferred, rather than proven by randomized clinical trials. Death in patients with untreated atrioventricular AV block is due not only to heart failure HF secondary to low cardiac output, but also to sudden cardiac death caused by prolonged asystole or bradycardia-triggered ventricular tachyarrhythmia.
Although formal randomized controlled trials RCTs of pacing in AV block have not been performed, it is clear from several observational studies that pacing prevents recurrence of syncope and improves survival in adults and in children see section 4. In patients with first-degree AV block and type I second-degree AV block with marked PR prolongation, small uncontrolled trials have suggested symptomatic and functional improvement, with normalization of the PR interval with dual-chamber pacing AV resynchronization.
There is no evidence that cardiac pacing prolongs survival in patients with sinus node dysfunction. Indeed, total survival and the risk of sudden cardiac death of patients with sick sinus syndrome SSS irrespective of symptoms are similar to that of the general population.
In a literature review, w18 systemic embolism occurred in There are no controlled trials comparing embolic events in untreated and treated patients. In a systematic review of large randomized trials, 2 there was a significant reduction in stroke hazard ratio [HR]: 0. Since the prognosis is benign— similar to that of the general population—the only reason for cardiac pacing is to prevent traumatic recurrent syncope. In general, when a transient or reversible cause is excluded, the indication for cardiac pacing is determined by the severity of bradycardia, rather than its aetiology.
Classification of bradyarrhythmias based on the patient's clinical presentation. The main physiological effect of bradycardia is to decrease cardiac output. As long as changes in stroke volume compensate for the decrease in heart rate, patients with profound bradycardia can remain completely asymptomatic. While the permanent forms of bradyarrhythmia are caused by an intrinsic disease of the sinus node or AV conduction system, the aetiology of intermittent bradyarrhythmia can be difficult to determine.
In conclusion, whilst persistent bradycardia clearly indicates an intrinsic AV block or SSS, the meaning of intermittent bradycardia is less clear, resulting from variable contributions of intrinsic and extrinsic mechanisms. Often the same event i.
The problem is further complicated by the fact that the diagnosis of intermittent bradycardia is often only presumed but not documented by electrocardiogram ECG.
In general, a reflex mechanism is more likely to be invoked when intermittent bradycardia is not documented, whereas if bradycardia is documented, it will be classified as AV block or SSS. Sinus bradycardia SB and AV block can be entirely asymptomatic in young, healthy individuals or during sleep, but patients with sustained or frequent bradyarrhythmia are often symptomatic. Easy fatigability, reduced exercise capacity and symptoms of HF are common in persistent bradyarrhythmia.
Subtle symptoms are irritability, lassitude, inability to concentrate, apathy, forgetfulness and dizziness. The diagnosis of bradyarrhythmia is usually made from a standard ECG when persistent, and from a standard ECG or more prolonged ECG recordings [ambulatory monitoring or implantable loop recorder ILR ] when intermittent. Since there is no defined heart rate below which treatment is indicated, correlation between symptoms and bradyarrhythmia is essential when deciding on the need for cardiac pacing therapy.
This can be difficult to establish in patients with competing mechanisms for their symptoms—for example, HF or pulmonary disease. Another common dilemma is the patient with persistent bradycardia and intermittent symptoms—for example, syncope in patients with mild persistent SB or permanent AF with low ventricular rate.
When an intermittent bradyarrhythmia is suspected but not proven, the suspicion should be corroborated by an ECG documentation of bradyarrhythmia or, alternatively, by laboratory testing.
ECG monitoring. Short-term monitoring Holter, telemetry and external loop recorder is useful, soon after the index episode, in patients who have very frequent symptoms at least once per week. The diagnostic yield of ILR is a function of the duration of the monitoring. Laboratory testing. The assumption is that provoked abnormalities will have the same mechanism as a spontaneous episode. Tilt table testing and carotid sinus massage are indicated when reflex syncope is suspected in the setting of an atypical non-diagnostic per se presentation.
EPS is indicated when syncope due to arrhythmia is suspected in patients with previous myocardial infarction, sinus bradycardia, bundle branch block BBB or sudden and brief undocumented palpitations. Exercise testing is indicated in patients who experience syncope during or shortly after exertion. Since false positive and negative responses are not uncommon for all these tests, the interpretation of responses requires knowledge of the clinical context in which spontaneous syncope occurred.
Diagnosing bradyarrhythmic syncope after the initial evaluation: most useful tests. The strategy of prolonged monitoring provides reliable evidence of diagnostic accuracy but diagnosis and therapy is delayed, often for a long time, until an event can be documented and the recurrent event may cause harm or even death.
Conversely, the strategy of laboratory tests has the advantage of an immediate diagnosis and therapy, but is hampered by a significant risk of misdiagnosis.
This section refers to acquired bradycardia in adults. Refer to section 4. In general, SB is only an indication for pacing if bradycardia is symptomatic. Symptoms may be present at rest but more frequently develop during exercise. The effect of cardiac pacing on the natural history of bradyarrhythmias comes from old non-randomized studies performed at the beginning of the PM era, which suggested a symptomatic improvement with cardiac pacing.
During follow-up, the occurrence of syncope and HF were lower in the PM group than in the other groups. Because cardiac pacing is not known to prolong survival in patients with sinus node dysfunction, permanent pacing is currently used to relieve symptoms attributed to bradycardia in patients with sinus node disease. If a cause—effect relationship between bradycardia and symptoms is excluded, cardiac pacing is not indicated. However, in many patients, the clinical manifestations of sinus node disease are more insidious and it is unclear whether symptoms can be attributed to an inadequate heart rate response to activities of daily living.
Exercise testing including cardiopulmonary testing can be used to assess exercise capacity but the range of heart rates in response to exercise in individuals is wide and therefore standard criteria for chronotropic incompetence are unreliable.
A blunted response of heart rate to autonomic blockade with propranolol 0. During subsequent mean follow-up of 7. A multivariable analysis showed that bradycardiac patients had a lower mortality, suggesting a protective effect of bradycardia.
Clinical perspectives: Acquired atrioventricular block Recommendations 4, 5, and 6. Even if the quality of evidence is modest, there is a strong consensus that patients with symptomatic sinus node disease will benefit from cardiac pacing for symptom relief.
Owing to the modest quality of evidence and the large inter-patient variability that make it difficult to establish the nature of symptoms, the usefulness of cardiac pacing in patients with chronotropic incompetence is uncertain, and the decision should be made on a case-by-case basis. Even if the quality of evidence is modest, there is a strong consensus that asymptomatic patients with SB do not benefit from cardiac pacing. Patients with sinus node disease are generally old and frequently have a concomitant heart disease.
In these situations, the demonstration of a clear cause—effect relationship between symptoms and sinus node disease is often difficult to achieve.
It is crucial to distinguish between physiological bradycardia, due to autonomic conditions or training effects, and inappropriate bradycardia that requires permanent cardiac pacing. For example, SB even when it is 40—50 bpm while at rest or as slow as 30 bpm while sleeping is accepted as a physiological finding that does not require cardiac pacing in trained athletes. When bradycardia is induced or exacerbated by concomitant drugs affecting sinus node function, drug discontinuation should be considered as an alternative to cardiac pacing.
Reducing drug dose, however, may not resolve the bradycardia. In contrast to SB, AV block may require PM therapy for prognostic reasons and pacing may be indicated in asymptomatic patients.
Although formal RCTs of pacing in patients with third- or second-degree type 2 AV block have not been performed, several observational studies, performed at the beginning of the PM era, suggest that pacing prevents recurrence of syncope and improves survival in adults.
In second-degree type 1 AV block, the indication for permanent pacing is controversial, unless AV block causes symptoms or the conduction delay occurs at intra- or infra-His levels.
The progression to complete heart block is likely when there is a wide QRS complex.
Skip to search form Skip to main content You are currently offline. Some features of the site may not work correctly. DOI: Ellenbogen and B. Wilkoff and N. Kay and C.
The journal, published since , is the official publication of the Spanish Society of Cardiology and founder of the REC Publications journal family. Articles are published in both English an Spanish in its electronic edition. The Impact Factor measures the average number of citations received in a particular year by papers published in the journal during the two receding years. CiteScore measures average citations received per document published.
By Kenneth A. Ellenbogen, MD, Bruce L. Wilkoff, MD, G.
The disclosure forms of the authors and reviewers are available on the ESC website www. No commercial use is authorized. Permission can be obtained upon submission of a written request to Oxford University Press, the publisher of Europace and the party authorized to handle such permissions on behalf of the ESC. The ESC Guidelines represent the views of the ESC and were arrived at after careful consideration of the available evidence at the time they were written. Health professionals are encouraged to take them fully into account when exercising their clinical judgement.
Kenneth A. Ellenbogen, Bruce L.