Indications for Pacemaker Implantation

Class I Indications

• The American College of Cardiology recommends pacemaker implantation for complete heart block with symptomatic bradycardia, as this condition significantly impacts morbidity, mortality, and quality of life 1
• Complete heart block with congestive heart failure is a strong indication for pacemaker implantation, according to the American College of Cardiology 3
• The American Heart Association suggests that complete heart block with documented periods of asystole ≥3.0 seconds or escape rate <40 beats/min, even in asymptomatic patients, requires pacemaker implantation 3
• Pacemaker implantation is recommended for complete heart block requiring drugs that suppress escape pacemakers, as stated by the American College of Cardiology 3
• The American College of Cardiology indicates that complete heart block with confusional states that clear with temporary pacing is a strong indication for pacemaker implantation 3
• Second-degree AV block with symptomatic bradycardia is a strong indication for pacemaker implantation, according to the American College of Cardiology 3
• Type II second-degree AV block, even when asymptomatic, is considered a reasonable indication for pacemaker implantation by the American College of Cardiology 3, 1
• Advanced second-degree AV block persisting 10-14 days after cardiac surgery is a strong indication for pacemaker implantation, as suggested by the American Heart Association 2
• Bifascicular block with intermittent complete heart block and symptomatic bradycardia requires pacemaker implantation, according to the American College of Cardiology 4
• The American Heart Association recommends pacemaker implantation for bifascicular or trifascicular block with intermittent type II second-degree AV block 4
• External ophthalmoplegia with bifascicular blocks is a strong indication for pacemaker implantation, as stated by the American Academy of Ophthalmology 2
• Sinus node dysfunction with documented symptomatic bradycardia requires pacemaker implantation, according to the American College of Cardiology 2, 1
• Bradycardia-tachycardia syndrome requiring antiarrhythmic drugs other than digitalis or phenytoin is a strong indication for pacemaker implantation, as suggested by the American Heart Association 2
• Sinus node dysfunction with heart rates <40 beats/min and symptomatic bradycardia requires pacemaker implantation, according to the American College of Cardiology 5
• Persistent advanced second-degree or complete heart block after myocardial infarction is a strong indication for pacemaker implantation, as stated by the American College of Cardiology 1
• Transient advanced AV block with associated bundle branch block after myocardial infarction requires pacemaker implantation, according to the American Heart Association 1
• Congenital AV block with wide QRS escape rhythm or block below the His bundle is a strong indication for pacemaker implantation, as suggested by the American Academy of Pediatrics 2
• Hypersensitive carotid sinus syndrome with syncope due to cardioinhibitory reflex requires pacemaker implantation, according to the American College of Cardiology 6

Class II Indications

• Asymptomatic complete heart block with ventricular rates ≥40 beats/min may be considered for pacemaker implantation, as stated by the American College of Cardiology 3, 1
• Asymptomatic type II second-degree AV block may be considered for pacemaker implantation, according to the American College of Cardiology 3, 1
• Asymptomatic second or third-degree AV block with ventricular rate <45 beats/min when awake may be considered for pacemaker implantation, as suggested by the American Heart Association 2
• Complete AV block with ventricular rate <50 beats/min may be considered for pacemaker implantation, according to the American College of Cardiology 2
• Sinus node dysfunction with heart rates <40 beats/min when clear association between symptoms and bradycardia has not been documented may be considered for pacemaker implantation, as stated by the American College of Cardiology 5
• Bifascicular or trifascicular block with syncope not proven due to complete heart block may be considered for pacemaker implantation, according to the American College of Cardiology 1, 4
• Markedly prolonged HV interval (>100 msec) found during electrophysiological study may be considered for pacemaker implantation, as suggested by the American College of Cardiology 4

Class III Indications

• First-degree AV block without symptoms is not recommended for pacemaker implantation, as stated by the American College of Cardiology 3
• Asymptomatic fascicular block without AV block is not recommended for pacemaker implantation, according to the American College of Cardiology 4
• Sinus node dysfunction in asymptomatic patients, even with heart rate <40 beats/min, is not recommended for pacemaker implantation, as suggested by the American Heart Association 5, 6
• Transient AV block that returns to normal conduction within 1 week is not recommended for pacemaker implantation, according to the American College of Cardiology 2
• Asymptomatic congenital heart block without profound bradycardia is not recommended for pacemaker implantation, as stated by the American Academy of Pediatrics 2
• Sinus node dysfunction when symptoms are clearly documented not to be associated with slow heart rate is not recommended for pacemaker implantation, according to the American College of Cardiology 6

Special Considerations

• Symptomatic recurrent supraventricular tachycardia when drugs fail or produce intolerable side effects may be considered for pacemaker implantation, as suggested by the American Heart Association 6
• Symptomatic recurrent ventricular tachycardia after implantation of an automatic defibrillator may be considered for pacemaker implantation, according to the American College of Cardiology 6
• Recurrent supraventricular tachycardia as an alternative to drug therapy may be considered for pacemaker implantation, as stated by the American Heart Association 6
• Sinus bradycardia in trained athletes is physiologic and does not require pacing, according to the American College of Sports Medicine 7
• Correlation of symptoms with specific arrhythmias is essential before pacemaker implantation, as suggested by the American College of Cardiology 7
• The decision to use a pacemaker to control tachycardias should be made only after careful observation, according to the American Heart Association 6
• In patients with complete heart block, symptoms must be presumed to be due to heart block unless proven otherwise, as stated by the American College of Cardiology 8