indications for permanent cardiac pacemaker

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Indications

Acquired AV block in adults

pacing indicated
- complete heart block with any complication
  - symptomatic bradycardia
  - congestive heart failure
  - ectopy requiring pharmacologic suppression
  - asystole > 3.0 seconds
  - bradycardia < 40 beats/min
  - post AV junction ablation
  - myotonic dystrophy
  - confusional states that clear with temporary pacing
- 2nd degree AV block (type 1 or 2) with symptomatic bradycardia
- atrial fibrillation or flutter with symptomatic bradycardia related to AV nodal blocking agents necessary to control ventricular response
pacing controversial
- asymptomatic complete heart block with ventricular rate > 40 beats/min
- asymptomatic 2nd degree heart block type 2
- asymptomatic 2nd degree heart block type 1 at His bundle*
pacing unnecessary
- 1st degree AV block
- asymptomatic 2nd degree heart block type 1 at supra-His bundle (AV nodal) level

pacing indicated
- persistent advance 2nd degree or 3rd degree AV block in the His-Purkinje* system
- transient advanced AV block associated with bundle branch block
pacing controversial
- persistent advanced AV block
pacing unnecessary
- transient AV conduction disturbances in the absence of intraventricular conduction defects
- transient AV block with isolated left anterior hemiblock
- acquired left anterior hemiblock without AV block
- persistent 1st degree AV block with new bundle branch block

pacing indicated
- bifascicular block with intermittent complete heart block associated with symptomatic bradycardia
- bifascicular or trifascicular block with intermittent asymptomatic 2nd degree type 2 AV block
pacing controversial
- syncope that is not proven related to heart block
- markedly prolonged heart block
- pacing-induced infra-His block
pacing unnecessary
- fascicular block without AV block or symptoms
- fascicular block with asymptomatic 1st degree AV block

pacing indicated
- sinus node dysfunction with symptomatic bradycardia (may occur as a result of pharmaceutical therapy for which there are no long-term acceptable alternatives)
pacing controversial
- sinus node dysfunction occurring spontaneously or as a result of drug therapy, with heart rate < 40/min without clear association of symptoms with bradycardia
pacing unnecessary
- sinus node dysfunction with asymptomatic bradycardia, including those with heart rate < 40/min resulting from long-term pharmaceutical therapy
- sinus node dysfunction with symptoms found NOT be be associated with bradycardia

Hypersensitive carotid sinus & neovascular syndromes

pacing indicated
- recurrent syncope associated with clear, spontaneous events provoked by carotid sinus stimulation (minimal carotid sinus pressure induces asystole > 3.0 seconds in duration in the absence of medication that depresses the sinus node or AV conduction)
pacing controversial
- recurrent syncope without clear, provocative events & with a hypersensitive cardioinhibitory response
- syncope with associated bradycardia reproduced by tilt table testing with or without isoproterenol or other provocative measures (temporary pacing with a 2nd provocative test may determine benefit of pacemaker)
pacing unnecessary
- hyperactive cardiopulmonary response to carotid artery stimulation in the absence of symptoms
- vague symptoms, such as dizziness &/or lightheadedness, with a hyperactive cardioinhibitory response to carotid sinus stimulation
- recurrent syncope, lightheadedness, or dizziness in the absence of a cardioinhibitory response to carotid sinus stimulation

↑ Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 1017