Treatment
ÎÎPermanent pacemaker implantation is indicated for:
• third-degree and advanced second-degree AV block at any anatomic level:
▶▶ associated with bradycardia with symptoms (including heart failure [HF]) or
ventricular arrhythmias presumed to be due to AV block. (I-C)
▶▶ associated with arrhythmias and other medical conditions that require drug
therapy that results in symptomatic bradycardia. (I-C)
▶▶ in awake, symptom-free patients in sinus rhythm, with documented periods of
asystole ≥3.0 seconds or any escape rate <40 bpm, or with an escape rhythm
that is below the AV node. (I-C)
▶▶ in awake, symptom-free patients with AF and bradycardia with one or more
pauses of at least 5 seconds or longer. (I-C)
▶▶ after catheter ablation of the AV junction. (I-C)
▶▶ associated with postoperative AV block that is not expected to resolve after
cardiac surgery. (I-C)
▶▶ associated with neuromuscular diseases with AV block, such as myotonic
muscular dystrophy, Kearns-Sayre syndrome, Erb dystrophy (limb-girdle
muscular dystrophy), and peroneal muscular atrophy, with or without
symptoms. (I-B)
• second-degree AV block with associated symptomatic bradycardia regardless of
type or site of block. (I-B)
• asymptomatic persistent third-degree AV block at any anatomic site with average
awake ventricular rates of ≥40 bpm if cardiomegaly or left ventricular (LV)
dysfunction is present or if the site of block is below the AV node. (I-B)
• second- or third-degree AV block during exercise in the absence of myocardial
ischemia. (I-C)
ÎÎPermanent pacemaker implantation is reasonable for:
• persistent third-degree AV block with an escape rate >40 bpm in asymptomatic
adult patients without cardiomegaly. (IIa-C)
• asymptomatic second-degree AV block at intra- or infra-His levels found at
electrophysiological study. (IIa-B)
• first- or second-degree AV block with symptoms similar to those of pacemaker
syndrome or hemodynamic compromise. (IIa-B)
• asymptomatic type II second-degree AV block with a narrow QRS.
When type II second-degree AV block occurs with a wide QRS, including isolated right
bundle-branch block, pacing becomes a Class I recommendation. (See "Permanent
Pacing in Chronic Bifascicular Block.") (IIa-B)
ÎÎPermanent pacemaker implantation may be considered for:
• neuromuscular diseases such as myotonic muscular dystrophy, Erb dystrophy
(limb-girdle muscular dystrophy), and peroneal muscular atrophy with any degree
of AV block (including first-degree AV block), with or without symptoms, because
there may be unpredictable progression of AV conduction disease. (IIb-B)
• AV block in the setting of drug use and/or drug toxicity when the block is
expected to recur even after the drug is withdrawn. (IIb-B)
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