The ACC/AHA/HRS 2008 Guidelines for Device-based Therapy of Cardiac Rhythm Abnormalities: Their Relevance to the Cardiologist, Internist and Family Physician

Stephen C. Vlay, MD


J Invasive Cardiol. 2009;21(5):234-237. 

In This Article

Abstract and Introduction

The purpose of this review is to highlight the important and new features of the 2008 Guidelines published in Circulation, the Journal of the American College of Cardiology and Heart Rhythm Journal in 2008[1–3] and available online ( This comprehensive document, coauthored by a committee of highly respected physicians, contains 527 references, the latest of which have been used to update the current recommendations. The salient features of the guidelines for internal cardioverter-defibrillators (ICDs) and permanent pacemakers (PPMs) will be emphasized.

Risk stratification was accomplished by weighing the evidence from published trials. The highest level of evidence (A) is derived from several randomized clinical trials in multiple populations. With limited populations from a single randomized trial or nonrandomized studies, the level is graded as (B). With only limited populations, consensus or expert opinion, the level of evidence is (C). It is important to note that, in rare conditions, there may not be sufficient data for large randomized trials, and the consensus or expert opinion is the only data available.

The greater the potential benefit to the patient, the more reason there is to recommend the procedure. Thus, classes are established with the highest benefit >>> risk (Class I); benefit >> risk (Class IIA); benefit > or equal to risk (Class IIB). If the risk is ≥ to the benefit, the procedure is contraindicated and should not be performed (Class III).

The language used in the document is very specific and has a very definite meaning for therapy: Class I (is indicated, is recommended); Class IIa (is reasonable); Class IIb (may be considered); Class III (is not recommended). For this reason, in this review, the same terminology will be used, as will specific language as it applies to the disorder discussed.

The proper selection of the patient for a particular procedure is crucial, not only for the best care of the patient, but also for the healthcare system. With the current financial crisis and limited resources, it is important to correctly risk-stratify patients so they will receive appropriate treatment, that those who will benefit from device therapy not be overlooked, and that those who will not benefit will not receive an unnecessary device that will not prolong meaningful life (the last is a triple-negative, but the meaning is clear!).

The author recommends that physicians have the guidelines readily available. As an example of how the recommendations are applied, note one of the changes from the 2002 Guidelines. The MADIT-II criteria for an ICD were upgraded from Class IIA to Class I. As the level of evidence increased with more review of the data, the committee determined that if the patient meets the criteria (remote myocardial infarction [MI], ischemic cardiomyopathy, left ventricular ejection fraction (LVEF) ≤ 0.30, the procedure should be performed (rather than is reasonable to perform).

The committee made some general comments on the formulation of this document. Mortality refers to "all-cause mortality”. Comorbidities, life expectancy (defined as "reasonable expectation of survival with a good functional status for more than one year”) and quality of life should be addressed. Patients receiving devices should have a thorough search for all inciting causes (e.g., nonessential drug therapy that could be eliminated). The committee recognized that patients have the right to decline a recommendation, even if guidelines are met. They emphasized that guidelines apply to most patients, but may require modification for a situation that only the primary treating physician can evaluate.


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