Clinical Heart and Vascular Center
2018 ‘Guideline on Evaluation and Management of Patients with Bradycardia and Conduction Delay’ – What You Need to Know
By Mark Link, M.D.
Professor of Internal Medicine
The 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay was released at the AHA Scientific Sessions (see Kusumoto FM, et al. Circulation 6 Nov 2018. DOI: 10.1161/CIR.0000000000000628.) This comprehensive document updates the 2012 Guideline.
The recommendations for pacing have changed little since prior guidelines, with a few notable exceptions. Sinus node dysfunction is most often related to age-dependent progressive fibrosis. Pacing should be limited to those with symptoms due to bradycardia. Nocturnal bradycardia is common, and physicians should evaluate for sleep apnea. Pacing is not usually needed.
Patients with left bundle branch block (LBBB) should be evaluated for structural heart disease, with at least an echocardiogram. Even if asymptomatic, those with irreversible second-degree Mobitz type II atrioventricular block, or higher degree block, should be paced. Wenckebach block patients should be paced only for symptoms due to bradycardia.
For patients with a left ventricular ejection fraction (LVEF) between 36 percent and 50 percent who will be paced more than 40 percent of the time, CRT or HIS bundle pacing are recommended. Post-TAVR-induced LBBB is given a IIb indication for pacing, yet the authors acknowledge that we need more information. Patients/legally defined surrogates have the right to refuse PPM and withdraw pacing, even if life-threatening.
Sinus node dysfunction is most often related to age-dependent progressive fibrosis. Pacing should be limited to those with symptoms due to bradycardia. Nocturnal bradycardia is common, and physicians should evaluate for sleep apnea. Pacing is not usually needed.
To summarize, there are two key changes in these new guidelines.
First, HIS bundle pacing may now be considered in patients requiring frequent
ventricular pacing. Second, the guidelines allow increased patient autonomy in
refusing pacing and withdrawal of pacing, even if life-threatening.