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Device-Based Therapy of Cardiac Rhythm
Abnormalities
Summaries from the:
ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of
Cardiac Rhythm Abnormalities
Epstein AE et al. Heart Rhythm 2008;5:934-55
Permanent Pacemaker Implantation
ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of
Cardiac Rhythm Abnormalities
Fred Kusumoto, MD, FHRS
Mayo, Clinic
Jacksonville, FL
Causes of Bradycardia
Sinus Node Dysfunction
AV block
Kusumoto, ECG Interpretation: from Pathophysiology to Clinical Application 2009
www.HRSonline.org
Permanent Pacing: Sinus Node Dysfunction
Permanent pacing is recommended for symptomatic patients with
sinus node dysfunction
Important points:
 Presence of symptoms is the main determinant on whether or not to
recommend permanent pacing.
 No specific rate cut-off or pause duration.
 The phrase “chrontropic incompetence” is used to describe an inadequate
heart rate response to exercise. There is no standardized definition for
“chronotropic incompetence.”
 If bradycardia results from required medications, permanent pacing is
recommended.
 Use pacing systems that minimize ventricular pacing.
www.HRSonline.org
Permanent Pacing: Atrioventricular block
Permanent pacing is recommended for symptomatic patients with 2nd
or 3rd degree AV block and for asymptomatic patients with 2nd or 3rd
degree AV block where the site of AV block is below the AV node
Important points:
 No specific rate cut-off or duration.
 The presence or absence of symptoms and the site of AV block are the
main determinants for whether or not pacing therapy is recommended.
 Block below the AV node is associated with poorer prognosis and sudden
development of symptoms due to the unreliability of infranodal escape
rhythms.
 Block below the AV node is suggested by: Type II 2nd degree AV block,
wide QRS complex (either conducted or as an escape rhythm), exercise
induced, accompanying neuromuscular disorders.
www.HRSonline.org
Dual Chamber Pacemaker Function
Kusumoto and Goldschlager JAMA 2001
www.HRSonline.org