The most recent American College of Cardiology Foundation/American Heart Association/Heart
Rhythm Society (ACCF/AHA/HRS) guidelines related to pacemaker implantation were published
as part of a larger document related to device-based therapy.
1
While this document provides some comments on pacemaker mode selection and algorithms
to guide selection, it does not provide specific recommendations regarding choices
for single- or dual-chamber devices. Over the past 15 years multiple randomized trials
have compared a number of cardiovascular outcomes among patients randomized to atrial
or dual-chamber pacing vs those randomized to ventricular pacing. The purpose of this
2012 consensus Statement is to provide a state-of-the-art review of the field and
to report the recommendations of a consensus writing group, convened by HRS and ACCF,
on pacemaker device and mode selection. This document focuses on pacemaker device
and mode selection in the adult patient; therefore, many of the recommendations may
not be applicable to unique situations encountered in the pediatric population. These
recommendations summarize the opinion of the consensus writing group, based on an
extensive literature review as well as their own experience.- Epstein A.E.
- et al.
ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities:
a report of the American College of Cardiology/American Heart Association Task Force
on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline
Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices).
Heart Rhythm. 2008; 5: e1-e62
Keywords
Abbreviations:
ACCF (American College of Cardiology Foundation), AF (atrial fibrillation), AHA (American Heart Association), AV (atrioventricular), CI (confidence interval), HR (hazard ratio), HRS (Heart Rhythm Society), ICD (implantable cardioverter defibrillator), QALY (quality-adjusted life year), SND (sinus node dysfunction), VT (ventricular tachycardia)To read this article in full you will need to make a payment
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References
- ACC/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices).Heart Rhythm. 2008; 5: e1-e62
- 2009 focused update: ACCF/AHA guidelines for the diagnosis and management of heart failure in adults.J Am Coll Cardiol. 2009; 53: 1343-1382
- 2010 focused update of ESC guidelines on device therapy in heart failure.Europace. 2010; 12: 1526-1536
- ACCF/AHA Task Force on Practice Guidelines.(acc.org.2009) (Accessed June 2012)
- Quality of life and clinical outcomes in elderly patients treated with ventricular pacing as compared with dual-chamber pacing.N Engl J Med. 1998; 338: 1097-1104
- Effects of physiologic pacing versus ventricular pacing on the risk of stroke and death due to cardiovascular causes.N Engl J Med. 2000; 342: 1385-1391
- Canadian Trial of Physiological Pacing: effects of physiological pacing during long-term follow-up.Circulation. 2004; 109: 357-362
- Ventricular pacing or dual-chamber pacing for sinus-node dysfunction.N Engl J Med. 2002; 346: 1854-1862
- Cardiovascular outcomes with atrial-based pacing compared with ventricular pacing: meta-analysis of randomized trials, using individual patient data.Circulation. 2006; 114: 11-17
- A comparison of single-lead atrial pacing with dual-chamber pacing in sick sinus syndrome.Eur Heart J. 2011; 32: 686-696
- Is a dual-sensor pacemaker appropriate in patients with sino-atrial disease?.Pacing Clin Electrophysiol. 2006; 29: 34-40
- Impact of rate-modulated pacing on quality of life and exercise capacity—evidence from the Advanced Elements of Pacing Randomized Controlled Trial (ADEPT).Heart Rhythm. 2007; 4: 1125-1132
- Minimizing ventricular pacing to reduce atrial fibrillation in sinus-node disease.N Engl J Med. 2007; 357: 1000-1008
- Long-term follow-up of patients from a randomised trial of atrial versus ventricular pacing for sick-sinus syndrome.Lancet. 1997; 350: 1210-1216
- Atrioventricular conduction during long-term follow-up of patients with sick sinus syndrome.Circulation. 1998; 98: 1315-1321
- AV block and changes in pacing mode during long-term follow-up of 399 consecutive patients with sick sinus syndrome treated with an AAI/AAIR pacemaker.Pacing Clin Electrophysiol. 2001; 24: 358-365
- Clinical Cardiac Pacing, Defibrillation, and Resynchronization Therapy.in: Ellenbogen K. Pacing for sinus node disease: diagnosis, pathophysiology and prognosis. Elsevier, Philadelphia2011: 300-322
- Redefining physiologic pacing: lessons learned from recent clinical trials.Heart Rhythm. 2006; 3: 1367-1372
- The natural history of sick sinus syndrome.Pacing Clin Electrophysiol. 1986; 9: 1110-1114
- Natural history of sinus node disease treated with atrial pacing in 213 patients: implications for selection of stimulation mode.J Am Coll Cardiol. 1992; 20: 633-639
- Atrial fibrillation after DDDR pacemaker implantation.J Cardiovasc Electrophysiol. 2002; 13: 542-547
- Single-chamber versus dual-chamber pacing for high-grade atrioventricular block.N Engl J Med. 2005; 353: 145-155
- Subclinical atrial fibrillation and the risk of stroke.N Engl J Med. 2012; 366: 120-129
- The relationship between daily atrial tachyarrhythmia burden from implantable device diagnostics and stroke risk: the TRENDS study.Circ Arrhythm Electrophysiol. 2009; 2: 474-480
- ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines.Circulation. 2011; 123: e269-e3367
- Effect of pacing mode on health-related quality of life in the Canadian Trial of Physiologic Pacing.Am Heart J. 2003; 145: 430-437
- Pacemaker implantation and quality of life in the Mode Selection Trial (MOST).Heart Rhythm. 2006; 3: 653-659
- Relationship between pacemaker dependency and the effect of pacing mode on cardiovascular outcomes.Circulation. 2001; 103: 3081-3085
- The effect of atrial-based pacing on exercise capacity as measured by the 6-minute walk test: a substudy of the Canadian Trial of Physiological Pacing (CTOPP).Heart Rhythm. 2007; 4: 1024-1028
- The pacemaker syndrome—a matter of definition.Am J Cardiol. 1997; 79: 1226-1229
- True incidence of pacemaker syndrome.Pacing Clin Electrophysiol. 1990; 13: 1742-1750
- Clinical characteristics of patients intolerant to VVIR pacing.Am J Cardiol. 2000; 86: 59-63
- High incidence of pacemaker syndrome in patients with sinus node dysfunction treated with ventricular-based pacing in the Mode Selection Trial (MOST).J Am Coll Cardiol. 2004; 43: 2066-2071
- Dual chamber versus single chamber ventricular pacemakers for sick sinus syndrome and atrioventricular block.Cochrane Database Syst Rev. 2004; (CD003710)
- Pacemaker syndrome.Pacing Clin Electrophysiol. 1994; 17: 1-5
- The pacemaker syndrome.Ann Intern Med. 1985; 103: 420-429
- Adverse effect of ventricular pacing on heart failure and atrial fibrillation among patients with normal baseline QRS duration in a clinical trial of pacemaker therapy for sinus node dysfunction.Circulation. 2003; 107: 2932-2937
- Dual-chamber pacing or ventricular backup pacing in patients with an implantable defibrillator: the Dual Chamber and VVI Implantable Defibrillator (DAVID) Trial.JAMA. 2002; 288: 3115-3123
- Total atrioventricular nodal ablation increases atrial fibrillation burden in patients with paroxysmal atrial fibrillation despite continuation of antiarrhythmic drug therapy.J Cardiovasc Electrophysiol. 2003; 14: 1296-1301
- Long-term implications of cumulative right ventricular pacing among patients with an implantable cardioverter-defibrillator.Heart Rhythm. 2011; 8: 212-218
- High atrial antitachycardia pacing therapy efficacy is associated with a reduction in atrial tachyarrhythmia burden in a subset of patients with sinus node dysfunction and paroxysmal atrial fibrillation.Heart Rhythm. 2005; 2: 791-796
- The effects of right ventricular apical pacing on ventricular function and dyssynchrony implications for therapy.J Am Coll Cardiol. 2009; 54: 764-776
- DDD(R)-pacing, but not AAI(R)-pacing induces left ventricular desynchronization in patients with sick sinus syndrome: tissue-Doppler and 3D echocardiographic evaluation in a randomized controlled comparison.Europace. 2008; 10: 127-133
- Heart failure and echocardiographic changes during long-term follow-up of patients with sick sinus syndrome randomized to single-chamber atrial or ventricular pacing.Circulation. 1998; 97: 987-995
- Percent right ventricular pacing predicts outcomes in the DAVID trial.Heart Rhythm. 2005; 2: 830-834
- The clinical implications of cumulative right ventricular pacing in the Multicenter Automatic Defibrillator Trial II.J Cardiovasc Electrophysiol. 2005; 16: 359-365
- Right ventricular pacing and the risk of heart failure in implantable cardioverter-defibrillator patients.Heart Rhythm. 2006; 3: 1397-1403
- The relationship between right ventricular pacing and atrial fibrillation burden and disease progression in patients with paroxysmal atrial fibrillation: the long-MinVPACE study.Europace. 2011; 3: 815-820
- Reducing unnecessary right ventricular pacing with the managed ventricular pacing mode in patients with sinus node disease and AV block.Pacing Clin Electrophysiol. 2006; 29: 697-705
- Outcome of patients aged over 75 years who received a pacemaker to treat sinus node dysfunction.Arch Cardiovasc Dis. 2011; 104: 89-96
- Atrial fibrillation in patients with sick sinus syndrome: the association with PQ-interval and percentage of ventricular pacing.Europace. 2012; 14: 682-689
- Long-term outcomes in individuals with prolonged PR interval or first-degree atrioventricular block.JAMA. 2009; 301: 2571-2577
- The influence of atrial and ventricular pacing on the incidence of atrial fibrillation: a meta-analysis.Pacing Clin Electrophysiol. 2011; 4: 1593-1599
- Is dual-chamber programming inferior to single-chamber programming in an implantable cardioverter-defibrillator?.Circulation. 2007; 115: 9-16
- Bradycardia pacing-induced short-long-short sequences at the onset of ventricular tachyarrhythmias: a possible mechanism of proarrhythmia?.J Am Coll Cardiol. 2007; 50: 614-622
- Frequent recurrent polymorphic ventricular tachycardia during sleep due to managed ventricular pacing.Pacing Clin Electrophysiol. 2010; 33: 641-644
- Risk of managed ventricular pacing in a patient with heart block.Heart Rhythm. 2006; 3: 1384-1385
- A comparison of the acute and long-term hemodynamic effects of ventricular inhibited and atrial synchronous ventricular inhibited pacing.Circulation. 1982; 65: 846-855
- Cardiac output in single-lead VDD pacing versus rate-matched VVIR pacing.Am J Cardiol. 1995; 75: 904-907
- Natural history of MVP mode in a single centre cohort.Can J Cardiol. 2011; 27: S264-S265
- Pacemaker syndrome: clinical, hemodynamic, and neurohormonal features.in: Barold S.S. Mugica J. New Perspectives in Cardiac Pacing. Futura Publishing Co, Mt Kisco, NY1994: 85-112
- Congestive heart failure treated by the upgrade from VVI to DDD pacing.Acta Cardiol. 2000; 55: 41-43
- Mechanism of hemodynamic improvement by dual-chamber pacing for severe left ventricular dysfunction: an acute Doppler and catheterization hemodynamic study.J Am Coll Cardiol. 1995; 25: 281-288
- New insights into pacemaker syndrome gained from hemodynamic, humoral and vascular responses during ventriculo-atrial pacing.Am J Cardiol. 1990; 65: 53-59
- Canadian Trial of Physiologic Pacing. Progression to chronic atrial fibrillation after pacing: The Canadian Trial of Physiologic Pacing. CTOPP Investigators.J Am Coll Cardiol. 2001; 38: 167-172
- The role of exercise testing in chronic heart failure.Br Heart J. 1987; 58: 559-566
- A randomized double-blind crossover comparison of four rate-responsive pacing modes.J Am Coll Cardiol. 1991; 17: 696-706
- Is mode switching beneficial?.J Am Coll Cardiol. 1997; 30: 496-504
- Physiological pacing improves symptoms and increases exercise capacity in the elderly patient.Int J Cardiol. 1994; 46: 129-133
- DDD vs. VVI pacing in patients aged over 75 years with complete heart block: a double-blind crossover comparison.QJM. 1994; 87: 245-251
- A randomized, single-blind crossover comparison of the effects of chronic DDD and dual sensor VVIR pacing mode on quality-of- life and cardiopulmonary performance in complete heart block.Pacing Clin Electrophysiol. 1996; 19: 1320-1326
- Comparison of dual chamber and ventricular rate responsive pacing in patients over 75 with complete heart block.Br Heart J. 1995; 74: 397-402
- Double blind crossover comparison of the effects of dual chamber pacing (DDD) and ventricular rate adaptive (VVIR) pacing on neuroendocrine variables, exercise performance, and symptoms in complete heart block.Br Heart J. 1991; 65: 188-193
- The effectiveness and cost-effectiveness of dual-chamber pacemakers compared with single-chamber pacemakers for bradycardia due to atrioventricular block or sick sinus syndrome: systematic review and economic evaluation.Health Technol Assess. 2005; 9 (iii, xi–xiii, 1–246)
- Randomised controlled trial of physiological and ventricular pacing.Br Heart J. 1983; 50: 112-117
- A comparison of symptoms and intra-arterial ambulatory blood pressure during long term dual chamber atrioventricular synchronous (DDD) and ventricular demand (VVI) pacing.Br Heart J. 1987; 58: 34-39
- Longevity in patients with high degree atrioventricular block paced in the atrial synchronous or the fixed rate ventricular inhibited mode.Pacing Clin Electrophysiol. 1992; 15: 304-313
- ”Subclinical” pacemaker syndrome: a randomised study of symptom free patients with ventricular demand (VVI) pacemakers upgraded to dual chamber devices.Br Heart J. 1992; 67: 57-64
- Quality-of-life in DDDR pacing: atrioventricular synchrony or rate adaptation?.Pacing Clin Electrophysiol. 1994; 17: 1838-1843
- Quality-of-life during DDD and dual sensor VVIR pacing.Pacing Clin Electrophysiol. 1994; 17: 1844-1848
- DDD versus VVIR pacing in patients, ages 70 and over, with complete heart block.Pacing Clin Electrophysiol. 2010; 33: 583-589
- Improved cardiac function and quality of life following upgrade to dual chamber pacing after long-term ventricular stimulation.Eur Heart J. 2002; 23: 490-497
- Individualised quality of life after pacing.Europace. 2004; 6: 552-560
- The effect of pacemaker mode on cognitive function.Heart. 2005; 91: 1209-1210
- Clinical outcomes after ablation and pacing therapy for atrial fibrillation: a meta-analysis.Circulation. 2000; 101: 1138-1144
- Progression of permanent atrial fibrillation after atrioventricular junction ablation and dual-chamber pacemaker implantation in patients with paroxysmal atrial tachyarrhythmias.Am J Cardiol. 1998; 81: 351-354
- Prospective randomized study of ablation and pacing versus medical therapy for paroxysmal atrial fibrillation: effects of pacing mode and mode-switch algorithm.Circulation. 1999; 99: 1587-1592
- Randomized crossover comparison of DDDR versus VDD pacing after atrioventricular junction ablation for prevention of atrial fibrillation.Circulation. 2000; 102: 736-741
- Chronic atrial fibrillation in patients with paroxysmal atrial fibrillation, atrioventricular node ablation and pacemakers: determinants and treatment.Europace. 1999; 1: 30-34
- An evaluation of the strategy of maintenance of sinus rhythm by antiarrhythmic drug therapy after ablation and pacing therapy in patients with paroxysmal atrial fibrillation.Eur Heart J. 2002; 23: 892-900
- Multicenter, prospective, randomized safety and efficacy study of a new atrial-based managed ventricular pacing mode (MVP) in dual chamber ICDs.J Cardiovasc Electrophysiol. 2005; 16: 811-817
- Eliminating right ventricular pacing may not be best for patients requiring implantable cardioverter-defibrillators.Heart Rhythm. 2007; 4: 886-891
- Percent ventricular pacing with managed ventricular pacing mode in standard pacemaker population.Europace. 2008; 10: 151-155
- The world survey of cardiac pacing and cardioverter defibrillators: calendar year 2001.Pacing Clin Electrophysiol. 2004; 27: 955-964
- Value of VDD-pacing systems in patients with atrioventricular block: experience over a decade.Int J Cardiol. 2007; 122: 239-243
- Retrospective analysis of mode survival, reliability of atrial sensing and incidence of atrial tachyarrhythmias in 307 single-lead VDD pacemaker patients.Europace. 2006; 8: 855-858
- Higher sympathetic nerve activity during ventricular (VVI) than during dual-chamber (DDD) pacing.J Am Coll Cardiol. 1996; 28: 1753-1758
- Whither physiologic pacing?.Pacing Clin Electrophysiol. 2000; 23: 1193-1196
- Single-chamber ventricular pacing increases markers of left ventricular dysfunction compared with dual-chamber pacing.Europace. 2007; 9: 194-199
- Hemodynamic importance of preserving the normal sequence of ventricular activation in permanent cardiac pacing.Am Heart J. 1995; 129: 1133-1141
- Acute hemodynamic effects of right ventricular pacing site and pacing mode in patients with congestive heart failure secondary to either ischemic or idiopathic dilated cardiomyopathy.Am J Cardiol. 2000; 85: 1106-1109
- Carotid sinus syncope treated by pacing.Br Heart J. 1982; 47: 411-418
- Management of cardioinhibitory hypersensitive carotid sinus syncope with permanent cardiac pacing—a seventeen year prospective study.Can J Cardiol. 1985; 1: 86-91
- Long-term outcome of paced and nonpaced patients with severe carotid sinus syndrome.Am J Cardiol. 1992; 69: 1039-1043
- Ventricular and dual chamber pacing for treatment of carotid sinus syndrome.Pacing Clin Electrophysiol. 1989; 12: 582-590
- A study comparing VVI and DDI pacing in elderly patients with carotid sinus syndrome.Heart. 1997; 77: 553-557
- Method of pacing does not affect the recurrence of syncope in carotid sinus syndrome.Pacing Clin Electrophysiol. 2012; ([Epub ahead of print])https://doi.org/10.1111/j.1540-8159.2012.03375.x
- Comparison of cardiac pacing with drug therapy in the treatment of neurocardiogenic (vasovagal) syncope with bradycardia or asystole.N Engl J Med. 1993; 328: 1085-1090
- Second Vasovagal Pacemaker Study (VPS II): rationale, design, results, and implications for practice and future clinical trials.Card Electrophysiol Rev. 2003; 7: 411-415
- Pacemaker therapy for prevention of syncope in patients with recurrent severe vasovagal syncope: Second Vasovagal Pacemaker Study (VPS II): a randomized trial.JAMA. 2003; 289: 2224-2229
- The North American Vasovagal Pacemaker Study (VPS).J Am Coll Cardiol. 1999; 33: 16-20
- The expectation effect and cardiac pacing for refractory vasovagal syncope.Am J Med. 2007; 120: 54-62
- Cardiac pacing for prevention of recurrent vasovagal syncope.Ann Intern Med. 1995; 122: 204-209
- A randomized, double-blind, placebo-controlled study of permanent cardiac pacing for the treatment of recurrent tilt-induced vasovagal syncope.Eur Heart J. 2004; 25: 1741-1748
- International study on syncope of uncertain aetiology 3 (ISSUE 3): pacemaker therapy for patients with asystolic neurally-mediated syncope: rationale and study design.Europace. 2007; 9: 25-30
- Analysis of rhythm variation during spontaneous cardioinhibitory neurally-mediated syncope.Europace. 2007; 9: 305-311
- Permanent cardiac pacing in patients with the long QT syndrome.J Am Coll Cardiol. 1987; 10: 600-607
- Efficacy of permanent pacing in the management of high-risk patients with long QT syndrome.Circulation. 1991; 84: 1524-1529
- Combined use of beta-adrenergic blocking agents and long-term cardiac pacing for patients with the long QT syndrome.J Am Coll Cardiol. 1992; 20: 830-837
- Ventricular repolarization during uni and biventricular pacing in normal subjects.Int J Cardiol. 2011; ([Epub ahead of print])
- Impact of dual-chamber permanent pacing in patients with obstructive hypertrophic cardiomyopathy with symptoms refractory to verapamil and beta-adrenergic blocker therapy.Circulation. 1992; 85: 2149-2161
- Long-term results of dual-chamber (DDD) pacing in obstructive hypertrophic cardiomyopathy.Circulation. 1994; 90: 2731-2742
- Pacing in hypertrophic obstructive cardiomyopathy. A randomized crossover study.Eur Heart J. 1997; 18: 1249-1256
- Assessment of permanent dual-chamber pacing as a treatment for drug-refractory symptomatic patients with obstructive hypertrophic cardiomyopathy.Circulation. 1999; 99: 2927-2933
- Dual-chamber pacing for hypertrophic cardiomyopathy: a randomized, double-blind, crossover trial.J Am Coll Cardiol. 1997; 29: 435-441
- Ventricular pacemaker upgrade: experience, complications and recommendations.Heart. 1998; 79: 383-387
- Complication rates associated with pacemaker or implantable cardioverter-defibrillator generator replacements and upgrade procedures: results from the REPLACE registry.Circulation. 2010; 122: 1553-1561
- Cost-effectiveness of dual-chamber pacing compared with ventricular pacing for sinus node dysfunction.Circulation. 2005; 111: 165-172
- Cost-effectiveness of physiologic pacing: results of the Canadian Health Economic Assessment of Physiologic Pacing.Heart Rhythm. 2005; 2: 270-275
- Economic and health consequences of managing bradycardia with dual-chamber compared to single-chamber ventricular pacemakers in Italy.J Cardiovasc Med (Hagerstown). 2008; 9: 43-50
- Modelling the health benefits and economic implications of implanting dual-chamber vs. single-chamber ventricular pacemakers in the UK.Europace. 2006; 8: 449-455
- Going from evidence to recommendations.BMJ. 2008; 336: 1049-1051
- GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-996
Article info
Footnotes
Approved by the Heart Rhythm Society Board of Trustees, the American College of Cardiology Foundation Board of Trustees, the Society of Thoracic Surgeons, and the American Heart Association Science Advisory and Coordinating Committee in June of 2012.
The Heart Rhythm Society requests that this document be cited as follows: Gillis AM, Russo AM, Ellenbogen KA, Swerdlow CD, Olshanky B, Al-Khatib SM, Beshai JF, McComb JM, Nielsen JC, Philpott JM, Shen WK. HRS/ACCF expert consensus statement on pacemaker device and mode selection. HeartRhythm 2012;9:1344–1365.
Permissions: Modifications, alteration, enhancement and/or distribution of this document are not permitted without the express permission of the Heart Rhythm Society or the American College of Cardiology Foundation.
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Copyright
© 2012 Published by Elsevier Inc.
