*These recommendations generally follow the ACC/AHA Guidelines for the Management of Patients with Acute Myocardial Infarction. See the National Guideline Clearinghouse summary.

Class IIb

1. Persistent second- or third-degree AV block at the AV node level. (Level of evidence: B)

Class III

1. Transient AV block in the absence of intraventricular conduction defects. (Level of evidence: B) (Col & Weinberg, 1972)
2. Transient AV block in the presence of isolated left anterior fascicular block. (Level of evidence: B) (Ginks et al., 1977)
3. Acquired left anterior fascicular block in the absence of AV block. (Level of evidence: B) (Col & Weinberg, 1972)
4. Persistent first-degree AV block in the presence of bundle branch block that is old or age indeterminate. (Level of evidence: B)* (Col & Weinberg, 1972)

Recommendations for Permanent Pacing in Sinus Node Dysfunction

Class I

1. Sinus node dysfunction with documented symptomatic bradycardia, including frequent sinus pauses that produce symptoms. In some patients, bradycardia is iatrogenic and will occur as a consequence of essential long-term drug therapy of a type and dose for which there are no acceptable alternatives. (Level of evidence: C) (Kay, Estioko, & Wiener, 1982; Kusumoto & Goldschlager, 1996; Rasmussen, 1981)
2. Symptomatic chronotropic incompetence. (Level of evidence: C) (Kay, Estioko, & Wiener, 1982; Kusumoto & Goldschlager, 1996; Rasmussen, 1981; Linde-Edelstam et al., 1992; Gammage et al., 1991)

Class IIa

1. Sinus node dysfunction occurring spontaneously or as a result of necessary drug therapy with heart rate less than 40 bpm when a clear association between significant symptoms consistent with bradycardia and the actual presence of bradycardia has not been documented. (Level of evidence: C) (Shaw, Holman, & Gowers, 1980; Kay, Estioko, & Wiener, 1982; Kusumoto & Goldschlager, 1996; Rasmussen, 1981; Dreifus, Michelson, & Kaplinsky, 1983; Rubenstein et al., 1972)
2. Syncope of unexplained origin when major abnormalities of sinus node function are discovered or provoked in electrophysiologic studies. (Level of evidence: C) (Fisher, 1981; Reiffel & Kuehnert, 1994)

Class IIb

1. In minimally symptomatic patients, chronic heart rate less than 40 bpm while awake. (Level of evidence: C) (Shaw, Holman, & Gowers, 1980; Kay, Estioko, & Wiener, 1982; Kusumoto & Goldschlager, 1996; Rasmussen, 1981; Dreifus, Michelson, & Kaplinsky, 1983; Rubenstein et al., 1972)

Class III

1. Sinus node dysfunction in asymptomatic patients, including those in whom substantial sinus bradycardia (heart rate less than 40 bpm) is a consequence of long-term drug treatment.
2. Sinus node dysfunction in patients with symptoms suggestive of bradycardia that are clearly documented as not associated with a slow heart rate.
3. Sinus node dysfunction with symptomatic bradycardia due to nonessential drug therapy.

Recommendations for Permanent Pacemakers That Automatically Detect and Pace to Terminate Tachycardias

Class IIa

1. Symptomatic recurrent supraventricular tachycardia that is reproducibly terminated by pacing in the unlikely event that catheter ablation and/or drugs fail to control the arrhythmia or produce intolerable side effects. (Level of evidence: C) (Peters et al., 1985; Fisher et al., 1987; Den Dulk et al., 1984; Saksena et al., 1986; Barold et al., 1987)

Class IIb

1. Recurrent supraventricular tachycardia or atrial flutter that is reproducibly terminated by pacing as an alternative to drug therapy or ablation. (Level of evidence: C) (Peters et al., 1985; Fisher et al., 1987; Den Dulk et al., 1984; Saksena et al., 1986; Barold et al., 1987; Spurrell, Nathan, & Camm, 1984)

Class III

1. Tachycardias frequently accelerated or converted to fibrillation by pacing.
2. The presence of accessory pathways with the capacity for rapid anterograde conduction whether or not the pathways participate in the mechanism of the tachycardia.

Pacing Recommendations to Prevent Tachycardia

Class I

1. Sustained pause-dependent ventricular tachycardia (VT), with or without prolonged QT, in which the efficacy of pacing is thoroughly documented. (Level of evidence: C) (Eldar et al., 1987; Eldar et al., 1992)

Class IIa

1. High-risk patients with congenital long-QT syndrome. (Level of evidence: C) (Eldar et al., 1987; Eldar et al., 1992)

Class IIb

1. AV re-entrant or AV node re-entrant supraventricular tachycardia not responsive to medical or ablative therapy. (Level of evidence: C) (Fisher et al., 1987; den Dulk et al., 1984; Attuel et al., 1988)
2. Prevention of symptomatic, drug-refractory, recurrent atrial fibrillation in patients with coexisting sinus node dysfunction. (Level of evidence: B)

Class III

1. Frequent or complex ventricular ectopic activity without sustained VT in the absence of the long QT syndrome.
2. Torsade de Pointes VT due to reversible causes.

Recommendations for Permanent Pacing in Hypersensitive Carotid Sinus Syndrome and Neurocardiogenic Syncope

Class I

1. Recurrent syncope caused by carotid sinus stimulation; minimal carotid sinus pressure induces ventricular asystole of more than 3 seconds' duration in the absence of any medication that depresses the sinus node or AV conduction. (Level of evidence: C) (Peretz, Gerein, & Miyagishima, 1973; Brignole et al., 1991)

Class IIa

1. Recurrent syncope without clear, provocative events and with a hypersensitive cardioinhibitory response. (Level of evidence: C) (Peretz, Gerein, & Miyagishima, 1973; Brignole et al., 1991)
2. Significantly symptomatic and recurrent neurocardiogenic syncope associated with bradycardia documented spontaneously or at the time of tilt-table testing. (Level of evidence: B) (Sutton et al., 2000; Connolly et al., 1999; Sheldon et al., 1998; Ammirati, Colivicchi, & Santini, 2001)

Class III

1. A hyperactive cardioinhibitory response to carotid sinus stimulation in the absence of symptoms or in the presence of vague symptoms such as dizziness, light-headedness, or both. (Level of evidence: C)
2. Recurrent syncope, light-headedness, or dizziness in the absence of a hyperactive cardioinhibitory response. (Level of evidence: C)
3. Situational vasovagal syncope in which avoidance behavior is effective. (Level of evidence: C)

Recommendations for Permanent Pacing in Children, Adolescents, and Patients With Congenital Heart Disease

Class I

1. Advanced second- or third-degree AV block associated with symptomatic bradycardia, ventricular dysfunction, or low cardiac output. (Level of evidence: C)
2. Sinus node dysfunction with correlation of symptoms during age-inappropriate bradycardia. The definition of bradycardia varies with the patient's age and expected heart rate. (Level of evidence: B) (Ector, Rolies, & De Geest, 1983; Kay, Estioko, & Wiener, 1982; Mackintosh, 1981)
3. Postoperative advanced second- or third-degree AV block that is not expected to resolve or persists at least 7 days after cardiac surgery. (Levels of evidence: B, C) (Mackintosh, 1981; Lillebei et al., 1963)
4. Congenital third-degree AV block with a wide QRS escape rhythm, complex ventricular ectopy, or ventricular dysfunction. (Level of evidence: B) (Michaelsson, Jonzon, & Riesenfeld, 1995; Pinsky et al., 1982; Moak et al., 2001)
5. Congenital third-degree AV block in the infant with a ventricular rate <50 to 55 bpm or with congenital heart disease and a ventricular rate <70 bpm. (Level of evidence: B, C) (Pinsky et al., 1982; Michaelsson & Engle, 1972)
6. Sustained pause-dependent VT, with or without prolonged QT, in which the efficacy of pacing is thoroughly documented. (Level of evidence: B) (Eldar et al., 1987; Eldar et al., 1992; Moss et al., 1991; Viskin et al., 1996)

Class IIa

1. Bradycardia-tachycardia syndrome with the need for long-term antiarrhythmic treatment other than digitalis. (Level of evidence: C) (Gillette et al., 1991; Rhodes et al., 1995)
2. Congenital third-degree AV block beyond the first year of life with an average heart rate less than 50 bpm, abrupt pauses in ventricular rate that are two or three times the basic cycle length, or associated with symptoms due to chronotropic incompetence. (Level of evidence: B) (Dewey, Capeless, & Levy, 1987)
3. Long QT syndrome with 2:1 AV or third-degree AV block. (Level of evidence: B) (Trippel, Parsons, & Gillette, 1995; Solti et al., 1992)
4. Asymptomatic sinus bradycardia in the child with complex congenital heart disease with resting heart rate less than 40 bpm or pauses in ventricular rate more than 3 seconds. (Level of evidence: C)
5. Patients with congenital heart disease and impaired hemodynamics due to sinus bradycardia or loss of AV synchrony. (Level of evidence: C)

Class IIb

1. Transient postoperative third-degree AV block that reverts to sinus rhythm with residual bifascicular block. (Level of evidence: C) (Krongrad, 1978)
2. Congenital third-degree AV block in the asymptomatic infant, child, adolescent, or young adult with an acceptable rate, narrow QRS complex, and normal ventricular function. (Level of evidence: B) (Michaelsson, Jonzon, & Riesenfeld, 1995; Sholler & Walsh, 1989)
3. Asymptomatic sinus bradycardia in the adolescent with congenital heart disease with resting heart rate less than 40 bpm or pauses in ventricular rate more than 3 seconds. (Level of evidence: C)
4. Neuromuscular diseases 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.

Class III

1. Transient postoperative AV block with return of normal AV conduction. (Level of evidence: B) (Kertesz et al., 1996; Krongrad, 1978)
2. Asymptomatic postoperative bifascicular block with or without first-degree AV block. (Level of evidence: C)
3. Asymptomatic type I second-degree AV block. (Level of evidence: C)
4. Asymptomatic sinus bradycardia in the adolescent with longest RR interval less than 3 seconds and minimum heart rate more than 40 bpm. (Level of evidence: C) (Greenspan et al., 1988)

Pacing Recommendations for Hypertrophic Cardiomyopathy

Class I

1. Class I indications for sinus node dysfunction or AV block as previously described. (Level of evidence: C)

Class IIb

1. Medically refractory, symptomatic hypertrophic cardiomyopathy with significant resting or provoked LV outflow obstruction. (Level of evidence: A) (Fananapazir et al., 1994; Nishimura, Hayes, et al., 1996; Kappenberger et al., 1997; Nishimura, Symanski, et al., 1996; Maron et al., 1999)

Class III

1. Patients who are asymptomatic or medically controlled.
2. Symptomatic patients without evidence of LV outflow obstruction.

Pacing Recommendations for Dilated Cardiomyopathy

Class I

1. Class I indications for sinus node dysfunction or AV block as previously described. (Level of evidence: C)

Class IIa

1. Biventricular pacing in medically refractory, symptomatic New York Heart Association (NYHA) class III or class IV patients with idiopathic dilated or ischemic cardiomyopathy, prolonged QRS interval (greater than or equal to 130 milliseconds), LV end-diastolic diameter greater than or equal to 55 mm, and ejection fraction less than or equal to 35%. (Level of evidence: A) (Cazeau et al., 2001; Abraham et al., 2002)

Class III

1. Asymptomatic dilated cardiomyopathy.
2. Symptomatic dilated cardiomyopathy when patients are rendered asymptomatic by drug therapy.
3. Symptomatic ischemic cardiomyopathy when the ischemia is amenable to intervention.

Pacing Recommendations After Cardiac Transplantation

Class I

1. Symptomatic bradyarrhythmias/chronotropic incompetence not expected to resolve and other Class I indications for permanent pacing. (Level of evidence: C)

Class IIb

1. Symptomatic bradyarrhythmias/chronotropic incompetence that, although transient, may persist for months and require intervention. (Level of evidence: C)

Class III

1. Asymptomatic bradyarrhythmias after cardiac transplantation.

Recommendations for Implantable Cardioverter-Defibrillator (ICD) Therapy

Class I

1. Cardiac arrest due to ventricular fibrillation (VF) or ventricular tachycardia (VT) not due to a transient or reversible cause. (Level of evidence: A) (Mehta et al., 1992; Saksena et al., 1992; Bardy et al., 1992; Mirowski et al., 1980; Lehmann et al., 1988; Tchou et al., 1988; Fogoros, Fiedler, & Elson, 1987; Winkle et al., 1989; Fogoros et al., 1990; Newman et al., 1992; Powell et al., 1993; Crandall et al., 1993; PCD Investigator Group, 1994; Zipes & Roberts, 1995; Wever et al., 1996; The Antiarrhythmics versus Implantable Defibrillators (AVID) Investigators, 1997; Borggrefe et al., 1994; Morady et al., 1993; Wever et al., 1995; Krol & Saksena, 1996; Connelly et al., 2000; Kuck et al., 2000)
2. Spontaneous sustained VT in association with structural heart disease. (Level of evidence: B) (Mehta et al., 1992; Saksena et al., 1992; Bardy et al., 1992; Mirowski et al., 1980; Lehmann et al., 1988; Tchou et al., 1988; Fogoros, Fiedler, & Elson, 1987; Winkle et al., 1989; Fogoros et al., 1990; Newman et al., 1992; Powell et al., 1993; Crandall et al., 1993; Saksena, for the PCD Investigator Group, 1994; Zipes & Roberts, 1995; Wever et al., 1996)
3. Syncope of undetermined origin with clinically relevant, hemodynamically significant sustained VT or VF induced at electrophysiological study when drug therapy is ineffective, not tolerated, or not preferred. (Level of evidence: B) (Wever et al., 1996; Connelly et al., 2000; Saksena et al., 1996; Nisam et al., 1995; Axtell, Tchou, & Akhtar, 1991; Hook & Marchlinski, 1991; Leitch et al., 1991; Bocker et al., 1996)
4. Nonsustained VT in patients with coronary disease, prior myocardial infarction, LV dysfunction, and inducible VF or sustained VT at electrophysiological study that is not suppressible by a Class I antiarrhythmic drug. (Level of evidence: A) (Moss et al., 1996; Saksena et al., 1997; Buxton et al., 1999)
5. Spontaneous sustained VT in patients without structural heart disease not amenable to other treatments. (Level of evidence: C)

Class IIa

1. Patients with left ventricular ejection fraction of less than or equal to 30% at least 1 month post myocardial infarction and 3 months post coronary artery revascularization surgery. (Level of evidence: B) (Moss et al., 2002)

Class IIb

1. Cardiac arrest presumed to be due to VF when electrophysiological testing is precluded by other medical conditions. (Level of evidence: C) (Crandall et al., 1993; Wever et al., 1995; Bardy, Yee, & Jung, 1996; Groh et al., 1996)
2. Severe symptoms (e.g., syncope) attributable to ventricular tachyarrhythmias in patients awaiting cardiac transplantation. (Level of evidence: C) (Grimm et al., 1995; Sweeney et al., 1995)
3. Familial or inherited conditions with a high risk for life-threatening ventricular tachyarrhythmias such as long QT syndrome or hypertrophic cardiomyopathy. (Level of evidence: B) (Donoso, Adler, & Friedberg, 1964; DePasquale & Bruno, 1973; Garson et al., 1993; McKenna & Franklin, 1988; Fananapazir & Epstein, 1991; Wichter et al., 1993; Evans et al., 1993; Maron & Fananapazir, 1992; Kaminer et al., 1990)
4. Nonsustained VT with coronary artery disease, prior MI, LV dysfunction, and inducible sustained VT or VF at electrophysiological study. (Level of evidence: B) (Mehta et al., 1992; Tchou et al., 1988; Zipes & Roberts, 1995; Moss et al., 1996; Saksena et al., 1997; Mehta et al., 1993; Wilber et al., 1990)
5. Recurrent syncope of undetermined origin in the presence of ventricular dysfunction and inducible ventricular arrhythmias at electrophysiologic study when other causes of syncope have been excluded. (Level of evidence: C)
6. Syncope of unexplained origin or family history of unexplained sudden cardiac death in association with typical or atypical right bundle-branch block and ST-segment elevations (Brugada syndrome). (Level of evidence: C) (Brugada, Brugada, & Brugada, 2000; Priori et al., 2002)
7. Syncope in patients with advanced structural heart disease in whom thorough invasive and noninvasive investigations have failed to define a cause. (Level of evidence: C)

Class III

1. Syncope of undetermined cause in a patient without inducible ventricular tachyarrhythmias and without structural heart disease. (Level of evidence: C)
2. Incessant VT or VF. (Level of evidence: C)
3. VF or VT resulting from arrhythmias amenable to surgical or catheter ablation; for example, atrial arrhythmias associated with the Wolff-Parkinson-White syndrome, right ventricular outflow tract VT, idiopathic left ventricular tachycardia, or fascicular VT. (Level of evidence: C) (Morady et al., 1993; Stevenson et al., 1993; Gonska et al., 1994; Hindricks, 1993; Klein et al., 1992)
4. Ventricular tachyarrhythmias due to a transient or reversible disorder (e.g., AMI, electrolyte imbalance, drugs, trauma) when correction of the disorder is considered feasible and likely to substantially reduce the risk of recurrent arrhythmia. (Level of evidence: B) (Michaud et al., 2001; Michaud & Strickberger, 2001; Anderson et al., 1999)
5. Significant psychiatric illnesses that may be aggravated by device implantation or may preclude systematic follow-up. (Level of evidence: C) (Vlay et al., 1989; Luderitz et al., 1993)
6. Terminal illnesses with projected life expectancy less than 6 months. (Level of evidence: C)
7. Patients with coronary artery disease with LV dysfunction and prolonged QRS duration in the absence of spontaneous or inducible sustained or nonsustained VT who are undergoing coronary bypass surgery. (Level of evidence: B) (Bigger, 1997)
8. New York Heart Association (NYHA) Class IV drug-refractory congestive heart failure in patients who are not candidates for cardiac transplantation. (Level of evidence: C)

Definitions:

Level of Recommendation: The final recommendations for indications for device therapy are expressed in the standard ACC/AHA format as follows:

Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is beneficial, useful, and effective.

Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.

Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy.

Class IIb: Usefulness/efficacy is less well established by evidence/opinion.

Class III: Conditions for which there is evidence and/or general agreement that a procedure/treatment is not useful/effective and in some cases may be harmful.

Strength of Evidence:

1. Data derived from multiple randomized clinical trials involving a large number of individuals.
2. Data derived from a limited number of trials involving a comparatively small number of patients or from well-designed data analyses of nonrandomized studies or observational data registries.
3. Consensus opinion of experts

References open in a new window

Electronic copies: Available in Portable Document Format (PDF) from the American College of Cardiology Web site.

Electronic copies are also available in Portable Document Format from the American Heart Association (AHA) Web site and the North American Society of Pacing and Electrophysiology Web site.

Print copies: Single copies available from the American College of Cardiology, Resource Center, 9111 Old Georgetown Rd., Bethesda, MD 20814-1699; (800) 253-4636 (US only). Bulk reprints available from AHA, Public Information, 7272 Greenville Ave., Dallas TX 75231-4596; Reprint No. 71-0237.

Electronic copies: Available in Portable Document Format (PDF) from the American College of Cardiology (ACC), the American Heart Association (AHA), and the North American Society of Pacing and Electrophysiology (NASPE) Web sites.

Print copies: Single copies available from the American College of Cardiology, Resource Center, 9111 Old Georgetown Rd., Bethesda, MD 20814-1699; (800) 253-4636 (US only). Bulk reprints available from AHA, Public Information, 7272 Greenville Ave., Dallas TX 75231-4596; Reprint No. 71-0236.

The following is also available:

• ACC/AHA pocket guidelines for implantation of cardiac pacemakers and antiarrhythmia devices.

Electronic copies available from the ACC Web site: Pocket Guideline; or Pocket Guideline Palm Download.

Print copies available from ACC, Resource Center, 9111 Old Georgetown Rd, Bethesda, MD 20814-1699; (800) 253-4636 (US only). Bulk reprints available from AHA, Public Information, 7272 Greenville Ave, Dallas TX 75231-4596.