ESC Updates Guidance on Cardiac Pacing, Resynchronization Therapy

Megan Brooks

August 30, 2021

The European Society of Cardiology (ESC) has released updated guidelines for cardiac pacing and cardiac resynchronization therapy (CRT), which emphasize patient-centered care and shared decision-making.

The new guidelines were published online August 29 in the European Heart Journal to coincide with presentation at the ESC Congress 2021.   

They replace the 2013 pacing guidelines and were developed by an ESC task force with input from the European Heart Rhythm Association. 

While some clinical situations that require pacing are clear and have not changed over the years, many others have evolved since 2013, necessitating new recommendations, the guideline panel says.

These include pacing after syncope, pacing following transcatheter aortic valve implantation (TAVI), CRT for heart failure (HF) and for prevention of pacing-induced cardiomyopathy, and pacing in various infiltrative and inflammatory diseases of the heart, as well as in different cardiomyopathies.

The section on CRT has been expanded and updated and is now "totally aligned" with the ESC HF guidelines "as opposed to in the past where there were contradictions," said guideline co-chair Michael Glikson, MD, with Hebrew University Faculty of Medicine, Jerusalem, Israel.

The latest guidelines also include a new section on pacing the His bundle and the left bundle branch, he noted.

Another key aspect of the guidelines is the focus on appropriate work up of patients and tests that should be done prior to pacemaker implantation. "This may be very helpful," Glikson said.

"In this version of the guidelines, you will find a completely new section, which is entitled, 'Evaluation of the patient with suspected or documented bradycardia or conduction system disease'," said Jean-Claude Deharo, MD, PhD, with Hôpital de la Timone, Marseille, France.

"In this section, the taskforce wanted to emphasize the importance of performing in every patient with symptoms suggestive of bradycardia the rather simple but systematic approach of history, physical examination, ECG and cardiac imaging," Deharo added. 

The guidelines give a class I, level of evidence A recommendation to implantation of a CRT defibrillator (CRT-D) in patients who are candidates for an implantable cardioverter defibrillator and have an indication for CRT. 

"The principles of patient-centered care and shared decision-making should be used in the consultation both pre-operatively and during follow-up for patients considered for or living with a pacemaker or CRT," the guidelines state.

The guidelines advise that patients with clinical signs of infection and/or fever should not undergo pacemaker implantation until they have been afebrile for 24 hours.

They also recommend use of preoperative systemic antibiotic prophylaxis as the standard of care in pacemaker implantation procedures (class I, level A).

There is also a new focus in other areas, such as ways to minimize procedural risk and avoid complications of cardiac pacing; how to manage patients with pacemakers in special situations, such as when MRI or irradiation are needed; and how to follow patients with a pacemaker with emphasis on the use of remote monitoring.

Eur Heart J. Published online August 29, 2021. Full text

European Society of Cardiology (ESC) Congress 2021. Presented August 29, 2021.

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