ACC/AHA Practice Guidelines

ACC/AHA Guidelines for Implantation of Cardiac

Pacemakers and Antiarrhythmia Devices:
Executive Summary
A Report of the American College of Cardiology/
American Heart Association Task Force on Practice Guidelines
(Committee on Pacemaker Implantation)
Gabriel Gregoratos, MD, FACC, Chair; Melvin D. Cheitlin, MD, FACC; Alicia Conill, MD, FACP*;
Andrew E. Epstein, MD, FACC; Christopher Fellows, MD, FACC;
T. Bruce Ferguson, Jr, MD, FACC; Roger A. Freedman, MD, FACC; Mark A. Hlatky, MD, FACC;
Gerald V. Naccarelli, MD, FACC; Sanjeev Saksena, MD, MBBS, FACC;
Robert C. Schlant, MD, FACC; Michael J. Silka, MD, FACC

Executive Summary
I. Introduction
The publication of major studies dealing with the natural
history of bradyarrhythmias and tachyarrhythmias and major
advances in the technology of pacemakers and implantable
cardioverter-defibrillators (ICDs) has mandated this revision
of the 1991 ACC/AHA Guidelines for Implantation of Pacemakers and Antiarrhythmia Devices.
This executive summary appears in the April 7, 1998 issue
of Circulation. The full text of the guidelines, including the
ACC/AHA Class I, II, and III recommendations, is published
in the April 1998 issue of the Journal of the American
College of Cardiology. Reprints of both the executive summary and the full text are available from both organizations.
ACC/AHA Guidelines for Implantation of Cardiac Pacemakers and
Antiarrhythmia Devices: Executive Summary was approved by the
Board of Directors of the American College of Cardiology in October
1997 and the American Heart Association Science Advisory and Coordinating Committee in January 1998.
*Representative of the American College of Physicians. Representative of the Society of Thoracic Surgeons. Representative of the North
American Society of Pacing and Electrophysiology.
When citing this document, the ACC and the AHA request that the
following format be used: Gregoratos G, Cheitlin MD, Conill A, Epstein
AE, Fellows C, Ferguson TB Jr, Freedman RA, Hlatky MA, Naccarelli
GV, Saksena S, Schlant RC, Silka MJ. ACC/AHA guidelines for
implantation of cardiac pacemakers and antiarrhythmia devices: a report
of the ACC/AHA Task Force on Practice Guidelines (Committee on
Pacemaker Implantation). J Am Coll Cardiol. 1998;31:11751206.
A single reprint of this document (executive summary) is available by
calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Avenue, Dallas, TX 752314596. Ask for reprint No. 71-0136. To obtain a reprint of the full text of
the guidelines published in the April issue of the Journal of the American
College of Cardiology, ask for reprint No. 71-0137. To purchase
additional reprints, specify version reprint number: up to 999 copies, call
800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies, call
214-706-1466, fax 214-691-6342, or E-mail [email protected]. To
make photocopies for personal or educational use, call the Copyright
Clearance Center, 508-750-8400.
(Circulation. 1998;97:1325-1335.)
1998 American College of Cardiology and American Heart Association, Inc.

Following extensive review of the medical literature and

related documents previously published by the American
College of Cardiology, the American Heart Association, and
the North American Society for Pacing and Electrophysiology, the writing committee developed recommendations that
are evidence based whenever possible.
Evidence supporting current recommendations is ranked as
level A if the data were derived from multiple randomized
clinical trials involving a large number of individuals. Evidence was ranked as level B when data were derived from a
limited number of trials involving comparatively small numbers of patients or from well-designed data analysis of
nonrandomized studies or observational data registries. Evidence was ranked as level C when consensus of expert
opinion was the primary source of recommendation. The
committee emphasizes that for certain conditions for which
no other therapies are available, the indications for device
therapies are based on years of clinical experience as well as
expert consensus and are thus well supported, even though
the evidence was ranked as level C.
These guidelines include expanded sections on selection of
pacemakers and ICDs, optimization of technology, cost, and
follow-up of implanted devices. The follow-up sections are
relatively brief because in many instances the type and
frequency of follow-up examinations are device specific. The
importance of adequate follow-up, however, cannot be overemphasized because optimal results from an implantable
device can be obtained only if the device is adjusted to
changing clinical conditions.
The text accompanying the list of indications should be
read carefully because it includes the rationale and supporting
evidence for many indications and in several instances
includes a discussion of alternative acceptable therapies.
Terms such as potentially reversible, persistent, transient, and not expected to resolve are frequently used.
These terms are not specifically defined because the time
element varies in different clinical settings. The treating
physician must use appropriate clinical judgment and available data in deciding whether a condition is persistent or

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Pacemaker Implantation Guidelines: Executive Summary

when it can be expected to be transient. The statement

incidental finding at electrophysiological study is used
several times in this document and does not imply such a
study is indicated. Appropriate indications for electrophysiological studies have been previously published.
The term symptomatic bradycardia is used frequently
throughout the guidelines and is defined as a documented
bradyarrhythmia that is directly responsible for the development of frank syncope or near-syncope, transient dizziness or
light-headedness, and confusional states resulting from cerebral hypoperfusion attributable to slow heart rate. Fatigue,
exercise intolerance, and frank congestive heart failure may
also result from bradycardia. These symptoms may occur at
rest or with exertion. Definite correlation of symptoms with a
bradyarrhythmia is a requirement to fulfill the criteria of
symptomatic bradycardia. Caution should be exercised not to
confuse physiological sinus bradycardia (as occurs in highly
trained athletes) with pathological bradyarrhythmias.
The section on indications for ICDs has been extensively
revised and enlarged to reflect emerging developments in this
field and the voluminous literature attesting to the efficacy of
these devices in the treatment of sudden cardiac death and
malignant ventricular arrhythmias. Indications for ICDs are
constantly changing and can be expected to change further as
ongoing large-scale trials are reported. In these guidelines the
term mortality is used to indicate all-cause mortality
unless otherwise specified. The committee elected to use
all-cause mortality because of the variable definition of
sudden death and the developing consensus to use allcause mortality as the most appropriate end point of clinical
trials.
The final recommendations for indications for device
therapy are expressed in the standard ACC/AHA format:
Class I: Conditions for which there is evidence and/or
general agreement that a given procedure or treatment is
beneficial, useful, and effective.
Class II: Conditions for which there is conflicting
evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.
Class IIa: Weight of evidence/opinion is in favor of
usefulness/efficacy.
Class IIb: Usefulness/efficacy is less well established
by evidence/opinion.
Class III: Conditions for which there is evidence and/or
general agreement that a procedure/treatment is not
useful/effective and in some cases may be harmful.

II. Indications for Permanent Pacing

A. Pacing for Acquired Atrioventricular Block
in Adults
Patients with abnormalities of atrioventricular (AV) conduction may be asymptomatic or may experience serious symptoms related to bradycardia, ventricular arrhythmias, or both.
Decisions about the need for a pacemaker are necessarily
influenced by the presence or absence of symptoms that are
directly attributable to bradycardia.
Nonrandomized studies strongly suggest that permanent
pacing improves survival in patients with third-degree AV

block, particularly if syncope has occurred. It is now recognized that marked first-degree AV block can lead to symptoms even in the absence of higher degrees of AV conduction
disturbance and may be associated with a pseudopacemaker
syndrome because of close proximity of atrial systole to the
preceding ventricular systole. Small uncontrolled trials have
suggested some symptomatic and functional improvement
with pacing in patients with PR intervals .0.30 second,
especially those with left ventricular (LV) dysfunction, some
of whom may benefit from dual-chamber pacing with short
AV delay.
Type I second-degree AV block is unlikely to progress to
advanced AV block when the delay is within the AV node.
Consequently, pacing is not usually indicated in this situation.
However, in patients with type II second-degree AV block
(either intra- or infra-His), symptoms are frequent, prognosis
is compromised, and progression to third-degree AV block is
common.
Physiological AV block in the presence of supraventricular
tachyarrhythmias is not an indication for pacemaker implantation except as specifically defined in the recommendations
below. Similarly, neurally mediated mechanisms in young
patients with AV block should be assessed before proceeding
with permanent pacing. Finally, permanent pacing for AV
block after valve surgery follows a variable natural history;
therefore, the decision for permanent pacing is at the physicians discretion.

Indications for Permanent Pacing in Acquired

Atrioventricular Block in Adults
Class I
1. Third-degree AV block at any anatomic level associated with any one of the following conditions:
a. Bradycardia with symptoms presumed to be due to
AV block. (Level of evidence: C)
b. Arrhythmias and other medical conditions that
require drugs that result in symptomatic bradycardia. (Level of evidence: C)
c. Documented periods of asystole >3.0 seconds or any
escape rate <40 beats per minute (bpm) in awake,
symptom-free patients. (Level of evidence: B, C)
d. After catheter ablation of the AV junction. (Level of
evidence: B, C) There are no trials to assess outcome
without pacing, and pacing is virtually always
planned in this situation unless the operative procedure is AV junction modification.
e. Postoperative AV block that is not expected to
resolve. (Level of evidence: C)
f. Neuromuscular diseases with AV block such as
myotonic muscular dystrophy, Kearns-Sayre syndrome, Erbs dystrophy (limb-girdle), and peroneal
muscular atrophy. (Level of evidence: B)
2. Second-degree AV block regardless of type or site of
block, with associated symptomatic bradycardia.
(Level of evidence: B)

Class IIa
1. Asymptomatic third-degree AV block at any anatomic
site with average awake ventricular rates of 40 bpm or
faster. (Level of evidence: B, C)

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Gregoratos et al
2. Asymptomatic type II second-degree AV block. (Level
of evidence: B)
3. Asymptomatic type I second-degree AV block at intra- or
infra-His levels found incidentally at electrophysiological
study for other indications. (Level of evidence: B)
4. First-degree AV block with symptoms suggestive of
pacemaker syndrome and documented alleviation of
symptoms with temporary AV pacing. (Level of evidence: B)

Class IIb
1. Marked first-degree AV block (>0.30 second) in patients with LV dysfunction and symptoms of congestive heart failure in whom a shorter AV interval
results in hemodynamic improvement, presumably by
decreasing left atrial filling pressure. (Level of evidence: C)

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1327

Indications for Permanent Pacing in Chronic

Bifascicular and Trifascicular Block
Class I
1. Intermittent third-degree AV block. (Level of evidence: B)
2. Type II second-degree AV block. (Level of evidence: B)

Class IIa
1. Syncope not proved to be due to AV block when other
likely causes have been excluded, specifically ventricular tachycardia (VT). (Level of evidence: B)
2. Incidental finding at electrophysiological study of
markedly prolonged HV interval (>100 milliseconds)
in asymptomatic patients. (Level of evidence: B)
3. Incidental finding at electrophysiological study of pacing-induced infra-His block that is not physiological.
(Level of evidence: B)

Class IIb
None.

Class III

Class III

1. Asymptomatic first-degree AV block. (Level of evidence: B) (See Pacing for Chronic Bifascicular and
Trifascicular Block.)
2. Asymptomatic type I second-degree AV block at the
supra-His (AV node) level or not known to be intra- or
infra-Hisian. (Level of evidence: B, C)
3. AV block expected to resolve and unlikely to recur (eg,
drug toxicity, Lyme disease). (Level of evidence: B)

B. Pacing for Chronic Bifascicular and

Trifascicular Block
Symptomatic advanced AV block that develops in patients
with underlying bifascicular and trifascicular block is associated with a high mortality rate and a significant incidence of
sudden death. However, there is considerable evidence that
the rate of progression of bifascicular block to third-degree
AV block is slow. Syncope is common in patients with
bifascicular block, and there is evidence that syncope in this
setting is associated with an increased incidence of sudden
cardiac death. Therefore, if the cause of syncope in the
presence of bifascicular or trifascicular block cannot be
determined with certainty, prophylactic permanent pacing is
indicated.
The PR and HV intervals have been identified as possible
predictors of third-degree AV block and sudden death in the
presence of underlying bifascicular block. However, the
prolongation is often at the level of the AV node, and
frequently there is no correlation between the PR and HV
intervals and progression to third-degree AV block and
incidence of sudden cardiac death. Some investigators have
suggested that asymptomatic patients with bifascicular block
and a prolonged HV interval ($100 milliseconds) should be
considered for permanent pacing. However, the incidence of
progression to third-degree AV block is low, even in the
setting of prolonged HV interval. Death is often not sudden or
due to advanced AV block but rather due to the underlying
heart disease itself and nonarrhythmic cardiac causes.

1. Fascicular block without AV block or symptoms.

(Level of evidence: B)
2. Fascicular block with first-degree AV block without
symptoms. (Level of evidence: B)

C. Pacing for Atrioventricular Block Associated

With Acute Myocardial Infarction
The long-term prognosis of survivors of acute myocardial
infarction (AMI) who develop AV block is related primarily
to the extent of myocardial damage and the character of
intraventricular conduction disturbances rather than the AV
block itself. Indications for permanent pacing in this setting
do not necessarily depend on the presence of symptoms.
Patients with AMI who develop intraventricular conduction
defects (with the exception of isolated left anterior fascicular
block) have an unfavorable short- and long-term prognosis
and an increased incidence of sudden death.
The decision to implant a permanent pacemaker for AV or
intraventricular conduction block complicating AMI will
depend on the type of conduction disturbance, location of the
infarction, and relation of the electrical disturbance to infarct
time. Thrombolytic therapy has decreased the incidence of
high-grade AV block in AMI, but mortality remains high in
this group of patients.
The impact of preexisting bundle branch block on mortality after AMI is uncertain. However, left bundle branch block
combined with advanced or third-degree AV block and right
bundle branch block combined with left anterior or left
posterior fascicular block carry a particularly ominous
prognosis.

Indications for Permanent Pacing After the Acute

Phase of Myocardial Infarction*
Class I
1. Persistent second-degree AV block in the His-Purkinje
system with bilateral bundle branch block or third*These recommendations generally follow the ACC/AHA Guidelines
for the Management of Patients with Acute Myocardial Infarction.

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Pacemaker Implantation Guidelines: Executive Summary

degree AV block within or below the His-Purkinje

system after AMI. (Level of evidence: B)
2. Transient advanced (second- or third-degree) infranodal AV block and associated bundle branch block. If
the site of block is uncertain, an electrophysiological
study may be necessary. (Level of evidence: B)
3. Persistent and symptomatic second- or third-degree
AV block. (Level of evidence: C)

genic and will occur as a consequence of essential longterm drug therapy of a type and dose for which there are
no acceptable alternatives. (Level of evidence: C)
2. Symptomatic chronotropic incompetence. (Level of
evidence: C)

Class IIa

Class IIb

1. Sinus node dysfunction occurring spontaneously or as

a result of necessary drug therapy with heart rate <40
bpm when a clear association between significant
symptoms consistent with bradycardia and the actual
presence of bradycardia has not been documented.
(Level of evidence: C)

1. Persistent second- or third-degree AV block at the AV

node level. (Level of evidence: B)

Class IIb

Class III

1. In minimally symptomatic patients, chronic heart rate

<30 bpm while awake. (Level of evidence: C)

Class IIa
None.

1. Transient AV block in the absence of intraventricular

conduction defects. (Level of evidence: B)
2. Transient AV block in the presence of isolated left
anterior fascicular block. (Level of evidence: B)
3. Acquired left anterior fascicular block in the absence
of AV block. (Level of evidence: B)
4. Persistent first-degree AV block in the presence of
bundle branch block that is old or age indeterminate.
(Level of evidence: B)

D. Pacing in Sinus Node Dysfunction

Class III
1. Sinus node dysfunction in asymptomatic patients, including those in whom substantial sinus bradycardia
(heart rate <40 bpm) is a consequence of long-term
drug treatment.
2. Sinus node dysfunction in patients with symptoms
suggestive of bradycardia that are clearly documented
as not associated with a slow heart rate.
3. Sinus node dysfunction with symptomatic bradycardia
due to nonessential drug therapy.

Correlation of symptoms with arrhythmias resulting from

sinus node dysfunction (eg, sinus bradycardia, sinus arrest,
paroxysmal supraventricular tachycardia alternating with periods of bradycardia or even asystole) is essential in deciding
whether a permanent pacemaker is indicated. This correlation
may be difficult because of the intermittent nature of the
episodes. Sinus node dysfunction may also express itself as
chronotropic incompetence. Rate-responsive pacemakers
have clinically benefited patients by restoring physiological
heart rate during physical activity in this setting.
Trained athletes may have a physiological sinus bradycardia of 40 to 50 bpm while awake and at rest and a sleeping
heart rate as low as 30 bpm with sinus pauses producing
asystolic intervals as long as 2.8 seconds. These findings are
due to increased vagal tone and are not an indication for
permanent pacing.
Permanent pacing in patients with sinus node dysfunction
will frequently relieve symptoms but may not necessarily
result in improved survival. Whether dual-chamber pacing
improves survival compared with ventricular pacing remains
controversial. Multiple prospective trials are ongoing to
assess the superiority of dual-chamber versus ventricularbased pacing systems in patients with sinus node dysfunction.

E. Prevention and Termination of

Tachyarrhythmias by Pacing

Indications for Permanent Pacing in Sinus

Node Dysfunction
Class I

Indications for Permanent Pacemakers That

Automatically Detect and Pace to
Terminate Tachycardias
Class I

1. Sinus node dysfunction with documented symptomatic

bradycardia, including frequent sinus pauses that produce symptoms. In some patients, bradycardia is iatro-

Pacing can be useful in terminating a variety of

tachyarrhythmias, including atrial flutter, paroxysmal reentrant supraventricular tachycardia, and VT. A variety of
pacing patterns have been used, including programmed stimulation and short bursts of rapid pacing. Antitachyarrhythmia
devices may detect the tachycardia and automatically activate
a pacing sequence or may respond to an external instruction
(eg, application of a magnet). Similarly, prevention of
tachyarrhythmias by pacing has been demonstrated in several
situations (eg, patients with the long QT syndrome and
recurrent pause-dependent VT). Combined therapy of pacing
and b-blockade has been reported to shorten the QT interval
and help prevent sudden cardiac death. Atrial synchronous
ventricular pacing may prevent recurrences of reentrant
supraventricular tachycardia, but this technique is rarely used
today, given the availability of catheter ablation and other
alternative therapies. In some patients with bradycardiadependent atrial fibrillation, atrial pacing may also be effective in reducing the frequency of recurrence. Dual-site and
biatrial pacing are actively being investigated as therapies for
symptomatic drug-refractory atrial fibrillation with concomitant bradyarrhythmias.

1. Symptomatic recurrent supraventricular tachycardia

that is reproducibly terminated by pacing after drugs

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Gregoratos et al
and catheter ablation fail to control the arrhythmia or
produce intolerable side effects. (Level of evidence: C)
2. Symptomatic recurrent sustained VT as part of an
automatic defibrillator system. (Level of evidence: B)

Class IIa
None.

Class IIb
1. Recurrent supraventricular tachycardia or atrial flutter that is reproducibly terminated by pacing as an
alternative to drug therapy or ablation. (Level of
evidence: C)

Class III
1. Tachycardias frequently accelerated or converted to
fibrillation by pacing.
2. The presence of accessory pathways with the capacity
for rapid anterograde conduction whether or not the
pathways participate in the mechanism of the
tachycardia.

Pacing Indications to Prevent Tachycardia

Class I
1. Sustained pause-dependent VT, with or without prolonged QT, in which the efficacy of pacing is thoroughly documented. (Level of evidence: C)

Class IIa
1. High-risk patients with congenital long QT syndrome.
(Level of evidence: C)

Class IIb
1. AV reentrant or AV node reentrant supraventricular
tachycardia not responsive to medical or ablative
therapy. (Level of evidence: C)
2. Prevention of symptomatic, drug-refractory, recurrent atrial fibrillation. (Level of evidence: C)

Class III
1. Frequent or complex ventricular ectopic activity without sustained VT in the absence of the long QT
syndrome.
2. Long QT syndrome due to reversible causes.

F. Pacing in Hypersensitive Carotid Sinus and

Neurally Mediated Syndromes
Hypersensitive carotid sinus syndrome is an uncommon
cause of syncope or presyncope. Symptoms in this setting
are mediated through both cardioinhibitory and vasodepressor reflexes. It is necessary to ascertain the relative
contribution of these two components of carotid sinus
stimulation before concluding that permanent pacing is
clinically indicated. Patients with symptoms due entirely
to the cardioinhibitory response of carotid sinus stimulation can be effectively treated with permanent pacing.
However, because 10% to 20% of patients also have an

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1329

important vasodepressor component in their reflex response, this component must be addressed as well.
Ten to forty percent of syncopal episodes are due to a
variety of neurally mediated syndromes, the most common
being vasovagal syncope. Considerable controversy exists
concerning the role of permanent pacing in refractory neurally mediated syncope associated with significant bradycardia or asystole because approximately 25% of patients have a
predominant vasodepressor reaction without significant bradycardia. There is conflicting evidence in the literature
regarding the efficacy of permanent pacing in neurally
mediated syncope, although a recent randomized trial in
highly symptomatic patients with bradycardia demonstrated
that permanent pacing increased the time to the first syncopal
event.

Indications for Permanent Pacing in

Hypersensitive Carotid Sinus Syndrome and
Neurally Mediated Syncope
Class I
1. Recurrent syncope caused by carotid sinus stimulation; minimal carotid sinus pressure induces ventricular asystole of >3 seconds duration in the absence of
any medication that depresses the sinus node or AV
conduction. (Level of evidence: C)

Class IIa
1. Recurrent syncope without clear, provocative events
and with a hypersensitive cardioinhibitory response.
(Level of evidence: C)
2. Syncope of unexplained origin when major abnormalities of sinus node function or AV conduction are
discovered or provoked in electrophysiological studies.
(Level of evidence: C)

Class IIb
1. Neurally mediated syncope with significant bradycardia reproduced by a head-up tilt with or without
isoproterenol or other provocative maneuvers. (Level
of evidence: B)

Class III
1. A hyperactive cardioinhibitory response to carotid
sinus stimulation in the absence of symptoms.
2. A hyperactive cardioinhibitory response to carotid
sinus stimulation in the presence of vague symptoms
such as dizziness, light-headedness, or both.
3. Recurrent syncope, light-headedness, or dizziness in
the absence of a hyperactive cardioinhibitory
response.
4. Situational vasovagal syncope in which avoidance behavior is effective.

G. Pacing in Children and Adolescents

Permanent pacing in children or adolescents is generally
indicated in (1) symptomatic sinus bradycardia, (2) recurrent
bradycardia-tachycardia syndromes, (3) congenital AV block,

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Pacemaker Implantation Guidelines: Executive Summary

and (4) advanced second- or third-degree surgically induced

or acquired AV block. Important differences between indications for permanent pacing in children and adults include (1)
age dependency of physiological heart rate and (2) impact of
residual ventricular dysfunction and abnormal circulatory
physiology after surgical palliation of complex congenital
cardiac defects.
Symptomatic bradycardia is an indication for pacemaker
implantation, provided other causes of symptoms have been
excluded. The bradycardia-tachycardia syndrome is an increasingly frequent problem in young patients after surgery
for congenital heart disease. Recurrent or chronic atrial flutter
is responsible for substantial morbidity and mortality in
young patients, and long-term atrial pacing at physiological
rates and atrial antitachycardia pacing have been used in this
setting. However, the results of permanent pacing to date
have been equivocal and the source of considerable
controversy.
The indications for permanent pacing in congenital thirddegree AV block have evolved with some studies suggesting
improved long-term survival and prevention of syncopal
episodes in asymptomatic patients with congenital complete
heart block who meet specific criteria. High-grade second- or
third-degree AV block persisting for 7 to 14 days after cardiac
surgery is an indication for permanent pacing. The need for
permanent pacing in patients with transient postoperative AV
block and residual bifascicular block has not been established, whereas patients with AV conduction that returns to
normal have a favorable prognosis.

Indications for Permanent Pacing in Children

and Adolescents
Class I
1. Advanced second- or third-degree AV block associated
with symptomatic bradycardia, congestive heart failure, or low cardiac output. (Level of evidence: C)
2. Sinus node dysfunction with correlation of symptoms
during age-inappropriate bradycardia. The definition
of bradycardia varies with the patients age and
expected heart rate. (Level of evidence: B)
3. Postoperative advanced second- or third-degree AV
block that is not expected to resolve or persists at least
7 days after cardiac surgery. (Level of evidence: B, C)
4. Congenital third-degree AV block with a wide QRS
escape rhythm or ventricular dysfunction. (Level of
evidence: B)
5. Congenital third-degree AV block in the infant with
a ventricular rate <50 to 55 bpm or with congenital
heart disease and a ventricular rate <70 bpm. (Level
of evidence: B, C)
6. Sustained pause-dependent VT, with or without prolonged QT, in which the efficacy of pacing is thoroughly documented. (Level of evidence: B)

Class IIa
1. Bradycardia-tachycardia syndrome with the need for
long-term antiarrhythmic treatment other than digitalis. (Level of evidence: C)

2. Congenital third-degree AV block beyond the first

year of life with an average heart rate <50 bpm or
abrupt pauses in ventricular rate that are two or three
times the basic cycle length. (Level of evidence: B)
3. Long QT syndrome with 2:1 AV or third-degree AV
block. (Level of evidence: B)
4. Asymptomatic sinus bradycardia in the child with
complex congenital heart disease with resting heart
rate <35 bpm or pauses in ventricular rate >3 seconds. (Level of evidence: C)

Class IIb
1. Transient postoperative third-degree AV block that
reverts to sinus rhythm with residual bifascicular
block. (Level of evidence: C)
2. Congenital third-degree AV block in the asymptomatic neonate, child, or adolescent with an acceptable rate,
narrow QRS complex, and normal ventricular function. (Level of evidence: B)
3. Asymptomatic sinus bradycardia in the adolescent
with congenital heart disease with resting heart rate
<35 bpm or pauses in ventricular rate >3 seconds.
(Level of evidence: C)

Class III
1. Transient postoperative AV block with return of normal
AV conduction within 7 days. (Level of evidence: B)
2. Asymptomatic postoperative bifascicular block with
or without first-degree AV block. (Level of evidence: C)
3. Asymptomatic type I second-degree AV block. (Level
of evidence: C)
4. Asymptomatic sinus bradycardia in the adolescent
when the longest RR interval is <3 seconds and the
minimum heart rate is >40 bpm. (Level of evidence: C)

H. Pacing in Specific Conditions

In patients with severely symptomatic hypertrophic cardiomyopathy, early nonrandomized studies demonstrated that
implantation of a dual-chamber pacemaker with a short AV
delay decreased the magnitude of LV outflow obstruction and
improved symptoms. However, recent observational studies
suggest that a decrease in LV outflow gradient produced by a
temporary dual chamber may adversely affect ventricular
filling and cardiac output. Recent randomized trials have
yielded variable results: one study demonstrated that DDD
pacing reduced outflow tract gradient and improved New
York Heart Association (NYHA) functional class, whereas
another randomized double-blind study demonstrated no significant subjective or exercise capacity improvement in the
paced versus nonpaced patient group at 2 to 3 months of
follow-up, despite a significant decrease in LV outflow
gradient. As a result, pacing indications for hypertrophic
cardiomyopathy remain controversial.

Pacing Indications for

Hypertrophic Cardiomyopathy
Class I
Class I indications for sinus node dysfunction or AV block
as previously described. (Level of evidence: C)

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Class IIa

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with previously stated Class I indications should have permanent pacing.

None.

Class IIb
1. Medically refractory, symptomatic hypertrophic cardiomyopathy with significant resting or provoked LV
outflow obstruction. (Level of evidence: C)

Class III
1. Patients who are asymptomatic or medically
controlled.
2. Symptomatic patients without evidence of LV outflow
obstruction.
Several nonrandomized trials of patients with symptomatic
dilated cardiomyopathy refractory to medical therapy have
reported limited improvement of symptoms with dual-chamber pacing with a short AV delay. However, at this time no
long-term data are available, and there is no consensus of
opinion for this indication. It has been hypothesized that a
well-timed atrial contraction primes the ventricles and decreases mitral regurgitation, thus augmenting stroke volume
and arterial pressure. However, one randomized controlled
trial showed no significant benefit of DDD pacing through a
range of PR intervals despite the presence of both tricuspid
and mitral regurgitation. Preliminary data suggest that simultaneous biventricular pacing may improve cardiac hemodynamics and lead to subjective and objective symptom improvement. This technique must still be considered
investigational at this time.

Pacing Indications for Dilated Cardiomyopathy

Class I
Class I indications for sinus node dysfunction or AV block
as previously described. (Level of evidence: C)

Class IIa
None.

Class IIb
1. Symptomatic, drug-refractory dilated cardiomyopathy with prolonged PR interval when acute hemodynamic studies have demonstrated hemodynamic
benefit of pacing. (Level of evidence: C)

Class III
1. Asymptomatic dilated cardiomyopathy.
2. Symptomatic dilated cardiomyopathy when patients
are rendered asymptomatic by drug therapy.
3. Symptomatic ischemic cardiomyopathy.
Bradyarrhythmias after cardiac transplantation are common,
occurring in 8% to 23% of patients with transplantation and
are usually associated with sinus node dysfunction. Although
some investigators have recommended more liberal use of
cardiac pacing for persistent postoperative bradycardia, approximately 50% of these patients demonstrate significant
improvement within 6 to 12 months after transplantation, and
therefore long-term pacing is often unnecessary. However,
patients with irreversible sinus node dysfunction or AV block

Pacing Indications After Cardiac Transplantation

Class I
1. Symptomatic bradyarrhythmias/chronotropic incompetence not expected to resolve and other Class I indications for permanent pacing. (Level of evidence: C)

Class IIa
None.

Class IIb
1. Symptomatic bradyarrhythmias/chronotropic incompetence that, although transient, may persist for
months and require intervention. (Level of evidence: C)

Class III
1. Asymptomatic bradyarrhythmias after cardiac transplantation.

I. Selection and Follow-up of Pacemaker Devices

Once a decision has been reached to implant a pacemaker,
the clinician may choose from a large number of pacemaker generators and leads. Generator choices include
single- versus dual-chamber devices, unipolar versus bipolar configuration, presence of rate responsiveness and
type of sensor used, advanced features such as automatic
mode switching, generator size, battery capacity, and cost.
Lead choices include polarity, type of insulation material,
active versus passive fixation mechanism, presence of
steroid elution, and typical pacing impedance. Other factors that frequently influence the choice of a pacemaker
system include the capabilities of the pacemaker programmer and local availability of technical support. Current
single-chamber pacemakers incorporate a number of programming features such as pacing mode, lower rate, pulse
width and amplitude, sensitivity, and refractory period.
Additional features of current dual-chamber pacemakers
include maximum tracking rate and AV delays. Rateresponsive pacemakers require programmable features to
regulate the relation between sensor output and pacing rate
and to limit the maximum sensor-driven pacing rate. These
programmable parameters must be individualized for each
patient. Many of these considerations are beyond the scope
of this document. The Table presents brief guidelines for
selecting the appropriate pacemaker for the most commonly encountered indications for pacing. Fig 1 depicts a
decision tree for selecting a pacing system for a patient
with AV block. Fig 2 depicts a decision tree for selecting
a pacing system for a patient with sinus node dysfunction.
It has been suggested that less sophisticated devices, eg,
single-chamber ventricular pacemakers or nonrate-responsive pacemakers, should be considered for elderly
patients who require pacing. However, a large retrospective analysis of elderly Medicare patients suggested that
dual-chamber pacing is associated with improved survival
compared with ventricular pacing even after correction for

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Pacemaker Implantation Guidelines: Executive Summary

Guidelines for Choice of Pacemaker Generator in Selected Indications for Pacing

Sinus Node Dysfunction

AV Block

Neurally Mediated Syncope or

Carotid Sinus Hypersensitivity

Single-chamber atrial
pacemaker

No suspected abnormality of AV
conduction and not at increased risk for
future AV block
Maintenance of AV synchrony during
pacing desired
Rate response available if desired

Not appropriate

Not appropriate (unless AV block

systematically excluded)

Single-chamber
ventricular pacemaker

Maintenance of AV synchrony
during pacing not necessary
Rate response available if desired

Chronic atrial fibrillation or other atrial

tachyarrhythmia or maintenance of AV
synchrony during pacing not necessary
Rate response available if desired

Chronic atrial fibrillation or other

atrial tachyarrhythmia
Rate response available if
desired

Dual-chamber pacemaker

AV synchrony during pacing desired

Suspected abnormality of AV conduction or
increased risk for future AV block
Rate response available if desired

AV synchrony during pacing desired

Atrial pacing desired
Rate response available if desired

Sinus mechanism present

Rate response available if desired

Single-lead, atrialsensing ventricular

pacemaker

Not appropriate

Normal sinus node function and no need for

atrial pacing
Desire to limit the number of pacemaker leads

Not appropriate

AV indicates atrioventricular.

confounding variables. On the basis of results of recently

published randomized and nonrandomized trials, rateresponsive ventricular pacing and dual-chamber pacing
appear to offer benefits over fixed-rate ventricular pacing
with respect to quality of life in elderly patients. However,
there may be no benefit of dual-chamber pacing over
rate-responsive ventricular demand pacing.

The cost of a pacemaker increases with its degree of

complexity and sophistication. At this time little is known
about the cost-effectiveness of the additional features of the
more complex pacemakers. Several ongoing trials assessing
the clinical benefits of dual-chamber or rate-responsive pacing include economic analysis to estimate the incremental
cost-effectiveness of these features. Optimal programming of

Figure 1. Selection of pacemaker systems for patients with atrioventricular block. AV indicates atrioventricular.

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Gregoratos et al

April 7, 1998

1333

Figure 2. Selection of pacemaker systems for patients with sinus node dysfunction. AV indicates atrioventricular.

output voltages, pulse widths, and AV delays can markedly

decrease battery drain and prolong generator life. It has been
shown that expert programming of pacemaker generators
may prolong their longevity by an average of 4.2 years
compared with nominal settings.
After implantation of a pacemaker, careful follow-up and
continuity of care are absolute requirements. Programming at
implantation must be reviewed before the patient is discharged and further refined at subsequent follow-up visits as
indicated by interrogation and testing. Frequency of follow-up is dictated by multiple factors, including other cardiovascular or medical problems managed by the physician
involved, the age of the pacemaker, and the results of
transtelephonic testing. Patients who are pacemaker dependent require more frequent clinical evaluations than those
who are not. Follow-up evaluation usually includes assessment of battery status, pacing threshold and pulse width,
sensing function, and lead integrity. The North American
Society of Pacing and Electrophysiology and the Health Care
Financing Administration have published reports on antibradycardia pacemaker follow-up and guidelines for monitoring
of patients with antibradycardia pacemakers, respectively.

III. Indications for Implantable

Cardioverter-Defibrillator Therapy
Three major therapeutic options are currently available to
reduce or prevent VT or ventricular fibrillation (VF) in
patients at risk for these arrhythmias: (1) antiarrhythmic drug
therapy selected by electrophysiological study or ambulatory
monitoring or prescribed empirically; (2) ablative techniques
used in cardiac surgery or percutaneously with catheter

techniques; and (3) implantation of an ICD. A combination of

ICD therapy with drugs or ablation is also frequently used.
Both early observational reports and more recent prospective
and sometimes randomized single-center and multicenter
trials with long-term outcome data uniformly document
sudden cardiac death recurrence rates of 1% to 2% annually
after device implantation compared with recurrences of 15%
to 25% without device therapy. Recent studies have recorded
major improvements in implantation risk, system longevity,
symptoms associated with arrhythmia recurrences, quality of
life, and diagnosis and management of delivery of inappropriate device therapy. Furthermore, the ICD has rapidly
evolved from a short-lived nonprogrammable device requiring thoracotomy for a lead insertion into a multiprogrammable antiarrhythmia device inserted almost exclusively
without thoracotomy and now capable of treating bradycardia, VT, and VF.
ICDs have been extensively evaluated in prospective clinical trials and clearly documented to revert sustained VTs,
including pace termination of sustained VT and shock reversion of VF. Early retrospective reports documented significant improvements in patient survival with the use of an ICD.
However, these studies tended to overestimate benefits by
using device therapies (antitachycardia pacing and shocks) as
surrogate mortality events. It has recently become apparent
that delivery of device therapy cannot be used as a surrogate
mortality end point, because arrhythmias other than VT/VF
can activate the device, and recurrent VT is not invariably
fatal. Considerable controversy exists about the appropriate
end point for evaluation of ICD efficacy, with many studies
using sudden death. However, classification of the cause of

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1334

Pacemaker Implantation Guidelines: Executive Summary

death is often difficult and imprecise; therefore, a consensus

has emerged that all-cause mortality is the appropriate
primary end point for judging ICD efficacy. Total mortality
has varied significantly between reports due to differences in
disease status of the population under study and LV function.
Survival of ICD recipients is greatly influenced by LV
function. Patients with an LV ejection fraction #30% have
reduced survival rates compared with those with higher
ejection fractions. However, both populations appear to
derive a significant survival benefit from ICD implantation.
A significant body of information is now available comparing the efficacy of antiarrhythmic drug therapy and ICDs
for the secondary prevention of cardiac arrest and sustained
VT. Evidence from both early retrospective nonrandomized
reports and more recent prospective randomized studies
comparing ICD therapy with Class III antiarrhythmic drug
therapy indicates a significant relative risk reduction with
ICD therapy at 1 and 3 years of follow-up. In a recently
reported large prospective trial, 98% of randomly selected
patients could be maintained on ICD therapy, with 25.4%
requiring the addition of drug therapy by 2 years. Therefore,
the addition of an antiarrhythmic drug for selected patients
with ICDs may improve their quality of life by reducing
recurrence of arrhythmias and the need for defibrillation.
Patients with coronary artery disease constitute the majority of patients receiving devices in most reports. Device
implantation is widely accepted today as improving the
outcome of these patients. It has been reported that patients
with impaired LV function may obtain greater benefit with
ICDs than with drug therapy. Optimal anti-ischemic therapy
including (when possible) a b-blocker should be used concomitantly with an ICD. In patients with marked elevation of
LV filling pressures, abbreviated defibrillation threshold
testing is desirable.
Patients with idiopathic dilated cardiomyopathy have a
high mortality rate within 2 years of diagnosis. Approximately half die suddenly and unexpectedly, and it has been
shown that the combination of poor LV function and frequent
episodes of nonsustained VT is associated with an increased
risk of sudden death. In a recently published large prospective
trial, patients with idiopathic dilated cardiomyopathy constituted 10% of the study group and showed similar survival
benefits with ICD therapy compared with empiric amiodarone therapy as the entire cohort. Similarly, ICD therapy has
been shown to confer a significant survival benefit in selected
patients with the long QT syndrome, hypertrophic cardiomyopathy, arrhythmogenic right ventricular dysplasia, idiopathic
VF, and syncope with inducible sustained VT.
Pediatric patients represent ,1% of persons with ICDs.
Nevertheless, ICD therapy is an important treatment option
for young patients, given the problems of noncompliance and
drug-induced side effects with lifelong pharmacological treatment. Sudden cardiac death is uncommon in childhood and is
mainly associated with three forms of heart disease: (1)
congenital heart disease, (2) cardiomyopathy, and (3) primary
electrical disease. It is noteworthy that a lower percentage of
children who undergo resuscitation survive to hospital discharge compared with adults.

Sudden death has been estimated to occur in 1.5% to 2.5%

of pediatric patients after repair of tetralogy of Fallot, and the
risk is even higher for patients with transposition of the great
arteries and aortic stenosis. Most cases are presumed to be
due to a malignant ventricular arrhythmia associated either
with ischemia, ventricular dysfunction, or rapid ventricular
response to atrial flutter. The risk of sudden cardiac death
may be greatest in young patients with diseases such as
hypertrophic cardiomyopathy or the long QT syndrome.
Family history of sudden cardiac death may be an important
indication for implantation of an ICD in a pediatric patient
with these conditions. Limited experience with ICDs in
young patients with hypertrophic cardiomyopathy after resuscitation has been encouraging.
ICD therapy is also used in patients with coronary artery
disease for the primary prevention of sudden cardiac death:
nonsustained VT in patients with prior MI and LV dysfunction carries a 2-year mortality estimate of 30%. Approximately half of this mortality is thought to be due to malignant
ventricular arrhythmias. In general, improved patient survival
with conventional antiarrhythmic drug therapy has not been
shown in this setting. Empiric amiodarone therapy has also
shown inconsistent survival benefit, although a recent metaanalysis suggests that total mortality may be reduced when
amiodarone is compared with other medical therapies. A
recent prospective randomized trial has documented improved survival of patients with inducible and nonsuppressible ventricular tachyarrhythmias treated with ICDs when
compared with antiarrhythmic drug therapy, including amiodarone. However, routine insertion of ICDs in patients
thought to be at high risk of sudden death who are undergoing
aortocoronary bypass graft surgery has not improved
survival.
ICDs are not recommended for a number of patients,
including those with ventricular tachyarrhythmias in evolving
AMI or with electrolyte abnormalities, those without inducible or spontaneous VT undergoing coronary bypass surgery,
and those with preexcitation syndrome presenting with VF as
a result of atrial fibrillation. Similarly, patients with terminal
illnesses or drug-refractory NYHA Class IV congestive heart
failure who are not candidates for cardiac transplantation are
likely to obtain limited benefit from ICD therapy. A history of
psychiatric disorders, including severe depression and substance abuse, that interfere with the meticulous care and
follow-up needed is also a relative contraindication to device
therapy.
In appropriately selected patients, ICDs have been found to
be cost-effective and comparable to other widely accepted
noncardiac therapies such as hemodialysis. A preliminary
analysis of a recent randomized clinical trial indicates that in
this group of patients, ICDs had a cost-effectiveness ratio of
$27,000 per life-year gained.

Indications for ICD Therapy

Class I
1. Cardiac arrest due to VF or VT not due to a transient
or reversible cause. (Level of evidence: A)
2. Spontaneous sustained VT. (Level of evidence: B)

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Gregoratos et al
3. Syncope of undetermined origin with clinically relevant, hemodynamically significant sustained VT or VF
induced at electrophysiological study when drug therapy is ineffective, not tolerated, or not preferred.
(Level of evidence: B)
4. Nonsustained VT with coronary disease, prior MI, LV
dysfunction, and inducible VF or sustained VT at
electrophysiological study that is not suppressible by a
Class I antiarrhythmic drug. (Level of evidence: B)

Class IIa
None.

Class IIb
1. Cardiac arrest presumed to be due to VF when
electrophysiological testing is precluded by other medical conditions. (Level of evidence: C)
2. Severe symptoms attributable to sustained ventricular
tachyarrhythmias while awaiting cardiac transplantation. (Level of evidence: C)
3. Familial or inherited conditions with a high risk for
life-threatening ventricular tachyarrhythmias such as
long QT syndrome or hypertrophic cardiomyopathy.
(Level of evidence: B)
4. Nonsustained VT with coronary artery disease, prior MI,
and LV dysfunction, and inducible sustained VT or VF
at electrophysiological study. (Level of evidence: B)
5. Recurrent syncope of undetermined etiology in the
presence of ventricular dysfunction and inducible ventricular arrhythmias at electrophysiological study
when other causes of syncope have been excluded.
(Level of evidence: C)

April 7, 1998

1335

Class III
1. Syncope of undetermined cause in a patient without
inducible ventricular tachyarrhythmias. (Level of evidence: C)
2. Incessant VT or VF. (Level of evidence: C)
3. VF or VT resulting from arrhythmias amenable to
surgical or catheter ablation; for example, atrial arrhythmias associated with the Wolff-Parkinson-White
syndrome, right ventricular outflow tract VT, idiopathic left ventricular tachycardia, or fascicular VT.
(Level of evidence: C)
4. Ventricular tachyarrhythmias due to a transient or
reversible disorder (eg, AMI, electrolyte imbalance,
drugs, trauma). (Level of evidence: C)
5. Significant psychiatric illnesses that may be aggravated by device implantation or may preclude systematic follow-up. (Level of evidence: C)
6. Terminal illnesses with projected life expectancy <6
months. (Level of evidence: C)
7. Patients with coronary artery disease with LV dysfunction and prolonged QRS duration in the absence
of spontaneous or inducible sustained or nonsustained VT who are undergoing coronary bypass
surgery. (Level of evidence: B)
8. NYHA Class IV drug-refractory congestive heart failure in patients who are not candidates for cardiac
transplantation. (Level of evidence: C)
KEY WORDS: AHA Medical/Scientific Statements
n arrhythmia

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pacemakers

pacing

ACC/AHA Guidelines for Implantation of Cardiac Pacemakers and Antiarrhythmia

Devices: Executive Summary: A Report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines (Committee on Pacemaker
Implantation)
Gabriel Gregoratos, Melvin D. Cheitlin, Alicia Conill, Andrew E. Epstein, Christopher Fellows,
T. Bruce Ferguson, Jr, Roger A. Freedman, Mark A. Hlatky, Gerald V. Naccarelli, Sanjeev
Saksena, Robert C. Schlant and Michael J. Silka
Circulation. 1998;97:1325-1335
doi: 10.1161/01.CIR.97.13.1325
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright 1998 American Heart Association, Inc. All rights reserved.
Print ISSN: 0009-7322. Online ISSN: 1524-4539

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http://circ.ahajournals.org/content/97/13/1325

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