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) developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons

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PRACTICE GUIDELINE: EXECUTIVE SUMMARY
ACC/AHA/HRS 2008 Guidelines for Device-Based
Therapy of Cardiac Rhythm Abnormalities:
Executive Summary
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)
Developed in Collaboration With the American Association for Thoracic Surgery and Society of Thoracic Surgeons
Writing
Committee
Members
Andrew E. Epstein, MD, FACC, FAHA,
FHRS, Chair*
John P. DiMarco, MD, PHD, FACC, FAHA,
FHRS*
Kenneth A. Ellenbogen, MD, FACC, FAHA,
FHRS*
N. A. Mark Estes, III, MD, FACC, FAHA, FHRS
Roger A. Freedman, MD, FACC, FHRS*
Leonard S. Gettes, MD, FACC, FAHA
A. Marc Gillinov, MD, FACC, FAHA*†
Gabriel Gregoratos, MD, FACC, FAHA
Stephen C. Hammill, MD, FACC, FHRS
David L. Hayes, MD, FACC, FAHA, FHRS*
Mark A. Hlatky, MD, FACC, FAHA
L. Kristin Newby, MD, FACC, FAHA
Richard L. Page, MD, FACC, FAHA, FHRS
Mark H. Schoenfeld, MD, FACC, FAHA, FHRS
Michael J. Silka, MD, FACC
Lynne Warner Stevenson, MD, FACC, FAHA‡
Michael O. Sweeney, MD, FACC*
*Recused from voting on guideline recommendations (see Section 1.2,
“Document Review and Approval,” for more detail); †American Asso-
ciation for Thoracic Surgery and Society of Thoracic Surgeons official
representative; ‡Heart Failure Society of America official representative
ACC/AHA
Task Force
Members
Sidney C. Smith, JR, MD, FACC, FAHA, Chair
Alice K. Jacobs, MD, FACC, FAHA, Vice-Chair
Cynthia D. Adams, RN, PHD, FAHA§
Jeffrey L. Anderson, MD, FACC, FAHA§
Christopher E. Buller, MD, FACC
Mark A. Creager, MD, FACC, FAHA
Steven M. Ettinger, MD, FACC
David P. Faxon, MD, FACC, FAHA§
Jonathan L. Halperin, MD, FACC, FAHA§
Loren F. Hiratzka, MD, FACC, FAHA§
Sharon A. Hunt, MD, FACC, FAHA§
Harlan M. Krumholz, MD, FACC, FAHA
Frederick G. Kushner, MD, FACC, FAHA
Bruce W. Lytle, MD, FACC, FAHA
Rick A. Nishimura, MD, FACC, FAHA
Joseph P. Ornato, MD, FACC, FAHA§
Richard L. Page, MD, FACC, FAHA
Barbara Riegel, DNSC, RN, FAHA§
Lynn G. Tarkington, RN
Clyde W. Yancy, MD, FACC, FAHA
§Former Task Force member during this writing effort
This document was approved by the American College of Cardiology Foundation Board of
Trustees, the American Heart Association Science Advisory and Coordinating Committee,
and the Heart Rhythm Society Board of Trustees in February 2008.
The American College of Cardiology Foundation, American Heart Association, and Heart
Rhythm Society request that this document be cited as follows: Epstein AE, DiMarco JP,
Ellenbogen KA, Estes NAM III, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G,
Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ,
Stevenson LW, Sweeney MO. ACC/AHA/HRS 2008 guidelines for device-based therapy of
cardiac rhythm abnormalities: executive summary: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Com-
mittee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of
Cardiac Pacemakers and Antiarrhythmia Devices). J Am Coll Cardiol 2008;51:2085–105.
This article has been copublished in the May 27, 2008, issue of Circulation and the June
2008 issue of Heart Rhythm.
Copies: This document is available on the World Wide Web sites of the American College
of Cardiology (www.acc.org), the American Heart Association (www.americanheart.org), and
the Heart Rhythm Society (www.hrsonline.org). For copies of this document, please contact
the Elsevier Inc. Reprint Department, fax (212) 633-3820, e-mail reprints@elsevier.com.
Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of
this document are not permitted without the express permission of the American College of
Cardiology Foundation, American Heart Association, or Heart Rhythm Society. Please
contact Elsevier’s permission department at healthpermissions@elsevier.com.
Journal of the American College of Cardiology Vol. 51, No. 21, 2008
© 2008 by the American College of Cardiology Foundation, the American Heart Association, Inc., and the Heart Rhythm Society ISSN 0735-1097/08/$34.00
Published by Elsevier Inc. doi:10.1016/j.jacc.2008.02.033
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TABLE OF CONTENTS
Preamble ....................................................2086
1. Introduction ............................................2087
1.1. Organization of Committee .......................2087
1.2. Document Review and Approval..................2087
1.3. Methodology and Evidence .......................2088
2. Recommendations for Permanent Pacing in
Sinus Node Dysfunction
..............................2090
3. Recommendations for Acquired Atrioventricular
Block in Adults
.........................................2091
4. Recommendations for Permanent Pacing in
Chronic Bifascicular Block
...........................2093
5. Recommendations for Permanent Pacing After
the Acute Phase of Myocardial Infarction
.........2093
6. Recommendations for Permanent Pacing in
Hypersensitive Carotid Sinus Syndrome and
Neurocardiogenic Syncope
..........................2093
7. Recommendations for Pacing After Cardiac
Transplantation
........................................2093
8. Recommendations for Permanent Pacemakers
That Automatically Detect and Pace to
Terminate Tachycardias
..............................2094
9. Recommendations for Pacing to Prevent
Tachycardia
.............................................2094
10. Recommendation for Pacing to Prevent
Atrial Fibrillation
.......................................2094
11. Recommendations for Cardiac Resynchronization
Therapy in Patients With Severe Systolic
Heart Failure
...........................................2094
12. Recommendations for Pacing in Patients With
Hypertrophic Cardiomyopathy
.......................2094
13. Recommendations for Permanent Pacing in
Children, Adolescents, and Patients With
Congenital Heart Disease
............................2095
14. Recommendations for Implantable
Cardioverter-Defibrillators
...........................2095
15. Recommendations for Implantable Cardioverter-
Defibrillators in Pediatric Patients and Patients
With Congenital Heart Disease
......................2097
References ..................................................2097
Appendix 1. Author Relationships With Industry......2101
Appendix 2. Peer Reviewer Relationships With
Industry
......................................................2103
Appendix 3. Abbreviations List ..........................2105
Preamble
It is important that the medical profession play a significant
role in critically evaluating the use of diagnostic procedures
and therapies as they are introduced and tested in the
detection, management, or prevention of disease states.
Rigorous and expert analysis of the available data docu-
menting absolute and relative benefits and risks of those
procedures and therapies can produce helpful guidelines
that improve the effectiveness of care, optimize patient
outcomes, and favorably affect the overall cost of care by
focusing resources on the most effective strategies.
The American College of Cardiology Foundation
(ACCF) and the American Heart Association (AHA) have
jointly engaged in the production of such guidelines in the
area of cardiovascular disease since 1980. The American
College of Cardiology (ACC)/AHA Task Force on Practice
Guidelines, whose charge is to develop, update, or revise
practice guidelines for important cardiovascular diseases and
procedures, directs this effort. Writing committees are
charged with the task of performing an assessment of the
evidence and acting as an independent group of authors to
develop, update, or revise written recommendations for
clinical practice.
Experts in the subject under consideration have been
selected from both organizations to examine subject-specific
data and write guidelines. The process includes additional
representatives from other medical practitioner and specialty
groups when appropriate. Writing committees are specifi-
cally charged to perform a formal literature review, weigh
the strength of evidence for or against a particular treatment
or procedure, and include estimates of expected health
outcomes where data exist. Patient-specific modifiers and
comorbidities and issues of patient preference that may
influence the choice of particular tests or therapies are
considered, as well as frequency of follow-up and cost-
effectiveness. When available, information from studies on
cost will be considered; however, review of data on efficacy
and clinical outcomes will constitute the primary basis for
preparing recommendations in these guidelines.
The ACC/AHA Task Force on Practice Guidelines
makes every effort to avoid any actual, potential, or per-
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ceived conflicts of interest that may arise as a result of an
industry relationship or personal interest of the writing
committee. Specifically, all members of the writing com-
mittee, as well as peer reviewers of the document, were
asked to provide disclosure statements of all such relation-
ships that may be perceived as real or potential conflicts of
interest. Writing committee members are also strongly
encouraged to declare a previous relationship with industry
that may be perceived as relevant to guideline development.
If a writing committee member develops a new relationship
with industry during his or her tenure, he or she is required
to notify guideline staff in writing. The continued partici-
pation of the writing committee member will be reviewed.
These statements are reviewed by the parent task force,
reported orally to all members of the writing committee at
each meeting, and updated and reviewed by the writing
committee as changes occur. Please refer to the methodol-
ogy manual for ACC/AHA guideline writing committees
for further description of the relationships with industry
policy (1). See Appendix 1 for author relationships with
industry and Appendix 2 for peer reviewer relationships
with industry that are pertinent to this guideline.
These practice guidelines are intended to assist health
care providers in clinical decision making by describing a
range of generally acceptable approaches for the diagnosis,
management, and prevention of specific diseases or condi-
tions. Clinical decision making should consider the quality
and availability of expertise in the area where care is
provided. These guidelines attempt to define practices that
meet the needs of most patients in most circumstances.
These guideline recommendations reflect a consensus of
expert opinion after a thorough review of the available
current scientific evidence and are intended to improve
patient care.
Patient adherence to prescribed and agreed upon medical
regimens and lifestyles is an important aspect of treatment.
Prescribed courses of treatment in accordance with these
recommendations will only be effective if they are followed.
Because lack of patient understanding and adherence may
adversely affect treatment outcomes, physicians and other
health care providers should make every effort to engage the
patient in active participation with prescribed medical reg-
imens and lifestyles.
If these guidelines are used as the basis for regulatory or
payer decisions, the ultimate goal is quality of care and serving
the patient’s best interests. The ultimate judgment regarding
care of a particular patient must be made by the health care
provider and the patient in light of all of the circumstances
presented by that patient. There are circumstances in which
deviations from these guidelines are appropriate.
The guidelines will be reviewed annually by the ACC/
AHA Task Force on Practice Guidelines and will be
considered current unless they are updated, revised, or
sunsetted and withdrawn from distribution. The executive
summary and recommendations are published in the May
27, 2008, issue of the Journal of the American College of
Cardiology, May 27, 2008, issue of Circulation, and the June
2008 issue of Heart Rhythm. The full-text guidelines are
e-published in the same issue of the journals noted above, as
well as posted on the ACC (www.acc.org), AHA (http://
my.americanheart.org), and Heart Rhythm Society (HRS)
(www.hrsonline.org) Web sites. Copies of the full-text and
the executive summary are available from each organization.
Sidney C. Smith, Jr, MD, FACC, FAHA
Chair, ACC/AHA Task Force on Practice Guidelines
1. Introduction
1.1. Organization of Committee
This revision of the “ACC/AHA/NASPE Guidelines for
Implantation of Cardiac Pacemakers and Antiarrhythmia
Devices” updates the previous versions published in 1984,
1991, 1998, and 2002. Revision of the statement was
deemed necessary for multiple reasons: 1) Major studies
have been reported that have advanced our knowledge of the
natural history of bradyarrhythmias and tachyarrhythmias,
which may be treated optimally with device therapy; 2)
there have been tremendous changes in the management of
heart failure that involve both drug and device therapy; and
3) major advances in the technology of devices to treat,
delay, and even prevent morbidity and mortality from
bradyarrhythmias, tachyarrhythmias, and heart failure have
occurred.
The committee to revise the “ACC/AHA/NASPE
Guidelines for Implantation of Cardiac Pacemakers and
Antiarrhythmia Devices” was composed of physicians who
are experts in the areas of device therapy and follow-up and
senior clinicians skilled in cardiovascular care, internal
medicine, cardiovascular surgery, ethics, and socioeconom-
ics. The committee included representatives of the Ameri-
can Association for Thoracic Surgery, Heart Failure Society
of America, and Society of Thoracic Surgeons.
1.2. Document Review and Approval
The document was reviewed by 2 official reviewers nomi-
nated by each of the ACC, AHA, and HRS and by 11
additional peer reviewers. Of the total 17 peer reviewers, 10
had no significant relevant relationships with industry. In
addition, this document has been reviewed and approved by
the governing bodies of the ACC, AHA, and HRS, which
include 19 ACC Board of Trustees members (none of
whom had any significant relevant relationships with indus-
try), 15 AHA Science Advisory Coordinating Committee
members (none of whom had any significant relevant
relationships with industry), and 14 HRS Board of Trustees
members (6 of whom had no significant relevant relation-
ships with industry). All guideline recommendations under-
went a formal, blinded writing committee vote. Writing
committee members were required to recuse themselves if
they had a significant relevant relationship with industry.
The guideline recommendations were unanimously ap-
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ACC/AHA/HRS Guidelines for Device-Based Therapy: Executive Summary
proved by all members of the writing committee who were
eligible to vote.
1.3. Methodology and Evidence
The recommendations listed in this document are, when-
ever possible, evidence based. An extensive literature survey
was conducted and limited to studies, reviews, and other
evidence conducted in human subjects and published in
English. Additionally, the committee reviewed documents
related to the subject matter previously published by the
ACC, AHA, and HRS. References selected and published
in this document are representative and not all-inclusive.
The committee reviewed and ranked evidence supporting
current recommendations, with the weight of evidence
ranked as Level A if the data were derived from multiple
randomized clinical trials that involved a large number of
individuals. The committee ranked available evidence as
Level B when data were derived either from a limited
number of trials that involved a comparatively small number
of patients or from well-designed data analyses of nonran-
domized studies or observational data registries. Evidence
was ranked as Level C when the consensus of experts was
the primary source of the recommendation. In the narrative
portions of these guidelines, evidence is generally presented
in chronological order of development. Studies are identi-
fied as observational, randomized, prospective, or retrospec-
tive. The committee emphasizes that for certain conditions
for which no other therapy is available, the indications for
device therapy are based on expert consensus and years of
clinical experience and are thus well supported, even though
the evidence was ranked as Level C. An analogous example
is the use of penicillin in pneumococcal pneumonia, for
which there are no randomized trials and only clinical
experience. When indications at Level C are supported by
historical clinical data, appropriate references (e.g., case
reports and clinical reviews) are cited if available. When
Level C indications are based strictly on committee consen-
sus, no references are cited. In areas where sparse data were
available (e.g., pacing in children and adolescents), a survey
of current practices of major centers in North America was
conducted to determine whether there was a consensus
regarding specific pacing indications.
The schema for classification of recommendations and
level of evidence is summarized in Table 1, which also
illustrates how the grading system provides an estimate of
the size of the treatment effect and an estimate of the
certainty of the treatment effect.
The focus of these guidelines is the appropriate use of
devices (e.g., pacemakers for bradyarrhythmias and heart
failure management, cardiac resynchronization, and im-
plantable cardioverter-defibrillators [ICDs]), not the treat-
ment of cardiac arrhythmias. The fact that the use of a
device for treatment of a particular condition is listed as a
Class I indication (beneficial, useful, and effective) does not
preclude the use of other therapeutic modalities that may be
equally effective. As with all clinical practice guidelines, the
recommendations in this document focus on treatment of an
average patient with a specific disorder and may be modified by
patient comorbidities, limitation of life expectancy because of
coexisting diseases, and other situations that only the primary
treating physician may evaluate appropriately.
The term “symptomatic bradycardia” is used in this
document. Symptomatic bradycardia is defined as a docu-
mented bradyarrhythmia that is directly responsible for
development of the clinical manifestations of syncope or
near syncope, transient dizziness or lightheadedness, or
confusional states resulting from cerebral hypoperfusion
attributable to slow heart rate. Fatigue, exercise intolerance,
and congestive heart failure may also result from bradycar-
dia. These symptoms may occur at rest or with exertion.
Definite correlation of symptoms with a bradyarrhythmia is
required to fulfill the criteria that define symptomatic
bradycardia. Caution should be exercised not to confuse
physiological sinus bradycardia (as occurs in highly trained
athletes) with pathological bradyarrhythmias. Occasionally,
symptoms may become apparent only in retrospect after
antibradycardia pacing. Nevertheless, the universal applica-
tion of pacing therapy to treat a specific heart rate cannot be
recommended except in specific circumstances, as detailed
subsequently.
In these guidelines, the terms “persistent,” “transient,”
and “not expected to resolve” are used but not specifically
defined because the time element varies in different clinical
conditions. The treating physician must use appropriate
clinical judgment and available data in deciding when a
condition is persistent or when it can be expected to be
transient.
Recommendations for ICD implantation have been up-
dated to reflect the numerous new developments in this field
and the voluminous literature related to the efficacy of these
devices in the treatment and prophylaxis of sudden cardiac
death (SCD) and malignant ventricular arrhythmias. Indi-
cations for ICDs, cardiac resynchronization therapy (CRT)
devices, and combined ICDs and CRT devices are contin-
uously changing and can be expected to change further as
new trials are reported. Indeed, it is inevitable that the
indications for device therapy will be refined with respect to
both expanded use and the identification of patients ex-
pected to benefit the most from these therapies. Further-
more, it is emphasized that when a patient has an indication
for both a pacemaker (whether it be single-chamber, dual-
chamber, or biventricular) and an ICD, a combined device
with appropriate programming is indicated.
The 2008 revision reflects what the committee believes
are the most relevant and significant advances in pacemaker/
ICD therapy since the publication of these guidelines in the
Journal of the American College of Cardiology and Circulation
in 2002 (2,3).
All recommendations assume that patients are treated
with optimal medical therapy according to published guide-
lines, as had been required in all the randomized controlled
2088 Epstein
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clinical trials on which these guidelines are based. The
committee believes that comorbidities, life expectancy, and
quality-of-life issues must be addressed forthrightly with
patients and their families. We have repeatedly used the
phrase “reasonable expectation of survival with a good
functional status for more than 1 year” to emphasize this
integration of factors in decision making. Even when
physicians believe that the anticipated benefits warrant
device implantation, patients have the option to decline
intervention after having been provided with a full explana-
tion of the potential risks and benefits of device therapy.
Finally, the committee is aware that other guidelines/expert
groups have interpreted the same data differently (4–7).
In preparing this revision, the committee was guided by
the following principles:
1. Changes in recommendations and levels of evidence
were made either because of new randomized trials or
Table 1. Applying Classification of Recommendations and Level of Evidence
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ACC/AHA/HRS Guidelines for Device-Based Therapy: Executive Summary
because of the accumulation of new clinical evidence and
the development of clinical consensus.
2. The committee was cognizant of the health care, logistic,
and financial implications of recent trials and factored in
these considerations to arrive at the classification of
certain recommendations.
3. For recommendations taken from other guidelines,
wording changes were made to render some of the
original recommendations more precise.
4. The committee would like to re-emphasize that the
recommendations in this guideline apply to most pa-
tients but may require modification because of existing
situations that only the primary treating physician can
evaluate properly.
5. All of the listed recommendations for implantation of a
device presume the absence of inciting causes that may
be eliminated without detriment to the patient (e.g.,
nonessential drug therapy).
6. The committee endeavored to maintain consistency of
recommendations in this and other previously published
guidelines. The recommendations on atrioventricular
(AV) block associated with acute myocardial infarction
closely follow those in the “ACC/AHA Guidelines for
the Management of Patients With ST-Elevation Myo-
cardial Infarction” (8). However, because of the rapid
evolution of pacemaker/ICD science, it has not always
been possible to maintain consistency with other pub-
lished guidelines.
The following represents the complete set of recommen-
dations for the implantation of antiarrhythmia devices. Prior
executive summaries of ACC/AHA guidelines have in-
cluded variable amounts of explanatory text ranging from
none to large amounts. Because the supporting text in the
full-text document was important to the present writing
committee, we decided to provide only the recommenda-
tions in the Executive Summary and recommend readers
access the full-text document for more explanation. Table 2
and Figures 1 and 2 are provided to help practitioners
choose which pacing device is appropriate for an individual
patient.
2. Recommendations for Permanent Pacing
in Sinus Node Dysfunction
CLASS I
1. Permanent pacemaker implantation is indicated for sinus node
dysfunction (SND) with documented symptomatic bradycardia,
including frequent sinus pauses that produce symptoms. (Level
of Evidence: C) (9–11)
2. Permanent pacemaker implantation is indicated for symptomatic
chronotropic incompetence. (Level of Evidence: C) (9–13)
3. Permanent pacemaker implantation is indicated for symptomatic
sinus bradycardia that results from required drug therapy for
medical conditions. (Level of Evidence: C)
CLASS IIa
1. Permanent pacemaker implantation is reasonable for SND 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) (9–11,14–16)
2. Permanent pacemaker implantation is reasonable for syncope of
unexplained origin when clinically significant abnormalities of
sinus node function are discovered or provoked in electrophysi-
ological studies. (Level of Evidence: C) (17,18)
CLASS IIb
1. Permanent pacemaker implantation may be considered in mini-
mally symptomatic patients with chronic heart rate less than 40
bpm while awake. (Level of Evidence: C) (9,11,12,14–16)
Table 2. Choice of Pacemaker Generator in Selected Indications for Pacing
Pacemaker Generator Sinus Node Dysfunction Atrioventricular Block
Neurally Mediated Syncope or
Carotid Sinus Hypersensitivity
Single-chamber atrial
pacemaker
No suspected abnormality of atrioventricular
conduction and not at increased risk for
future atrioventricular block
Not appropriate Not appropriate
Maintenance of atrioventricular synchrony
during pacing desired
Single-chamber ventricular
pacemaker
Maintenance of atrioventricular synchrony
during pacing not necessary
Rate response available if desired
Chronic atrial fibrillation or other atrial
tachyarrhythmia or maintenance of
atrioventricular synchrony during pacing not
necessary
Chronic atrial fibrillation or
other atrial tachyarrhythmia
Rate response available if
desired
Rate response available if desired
Dual-chamber pacemaker Atrioventricular synchrony during pacing
desired
Suspected abnormality of atrioventricular
conduction or increased risk for future
atrioventricular block
Rate response available if desired
Rate response available if desired
Atrioventricular synchrony during pacing desired
Atrial pacing desired
Rate response available if desired
Sinus mechanism present
Rate response available if
desired
Single-lead, atrial-sensing
ventricular pacemaker
Not appropriate Desire to limit the number of pacemaker leads Not appropriate
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CLASS III
1. Permanent pacemaker implantation is not indicated for SND in
asymptomatic patients. (Level of Evidence: C)
2. Permanent pacemaker implantation is not indicated for SND in
patients for whom the symptoms suggestive of bradycardia have
been clearly documented to occur in the absence of bradycardia.
(Level of Evidence: C)
3. Permanent pacemaker implantation is not indicated for SND with
symptomatic bradycardia due to nonessential drug therapy.
(Level of Evidence: C)
3. Recommendations for Acquired
Atrioventricular Block in Adults
CLASS I
1. Permanent 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) or ventricular arrhythmias presumed to be due to AV
block. (Level of Evidence: C) (15,19–21)
2. Permanent pacemaker implantation is indicated for third-degree
and advanced second-degree AV block at any anatomic level
associated with arrhythmias and other medical conditions that
require drug therapy that results in symptomatic bradycardia.
(Level of Evidence: C) (15,19–21)
3. Permanent pacemaker implantation is indicated for third-degree
and advanced second-degree AV block at any anatomic level in
awake, symptom-free patients in sinus rhythm, with documented
periods of asystole greater than or equal to 3.0 seconds (22) or
any escape rate less than 40 bpm, or with an escape rhythm that
is below the AV node. (Level of Evidence: C) (9,14)
4. Permanent pacemaker implantation is indicated for third-degree
and advanced second-degree AV block at any anatomic level in
awake, symptom-free patients with atrial fibrillation and brady-
cardia with 1 or more pauses of at least 5 seconds or longer.
(Level of Evidence: C)
5. Permanent pacemaker implantation is indicated for third-degree
and advanced second-degree AV block at any anatomic level
after catheter ablation of the AV junction. (Level of Evidence: C)
(23,24)
6. Permanent pacemaker implantation is indicated for third-degree
and advanced second-degree AV block at any anatomic level
associated with postoperative AV block that is not expected to
resolve after cardiac surgery. (Level of Evidence: C) (21,25–27)
7. Permanent pacemaker implantation is indicated for third-degree
and advanced second-degree AV block at any anatomic level
associated with neuromuscular diseases with AV block, such as
myotonic muscular dystrophy, Kearns-Sayre syndrome, Erb dys-
trophy (limb-girdle muscular dystrophy), and peroneal muscular
atrophy, with or without symptoms. (Level of Evidence: B) (28–34)
8. Permanent pacemaker implantation is indicated for second-
degree AV block with associated symptomatic bradycardia re-
gardless of type or site of block. (Level of Evidence: B) (35)
9. Permanent pacemaker implantation is indicated for asymptom-
atic persistent third-degree AV block at any anatomic site with
average awake ventricular rates of 40 bpm or faster if cardio-
megaly or left ventricular (LV) dysfunction is present or if the site
of block is below the AV node. (Level of Evidence: B) (20,36)
Figure 1. Selection of Pacemaker Systems for Patients With Sinus Node Dysfunction
Decisions are illustrated by diamonds. Shaded boxes indicate type of pacemaker. AV indicates atrioventricular.
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10. Permanent pacemaker implantation is indicated for second- or
third-degree AV block during exercise in the absence of myo-
cardial ischemia. (Level of Evidence: C) (37,38)
CLASS IIa
1. Permanent pacemaker implantation is reasonable for persistent
third-degree AV block with an escape rate greater than 40 bpm
in asymptomatic adult patients without cardiomegaly. (Level of
Evidence: C) (15,19–21,38,39)
2. Permanent pacemaker implantation is reasonable for asymptom-
atic second-degree AV block at intra- or infra-His levels found at
electrophysiological study. (Level of Evidence: B) (20,35,36)
3. Permanent pacemaker implantation is reasonable for first- or
second-degree AV block with symptoms similar to those of
pacemaker syndrome or hemodynamic compromise. (Level of
Evidence: B) (40,41)
4. Permanent pacemaker implantation is reasonable for asymptom-
atic 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 Section 2.1.3, “Chronic Bifascicular Block,”
in the full-text guidelines.) (Level of Evidence: B) (20,21,40,42)
CLASS IIb
1. Permanent pacemaker implantation may be considered for neu-
romuscular diseases such as myotonic muscular dystrophy, Erb
dystrophy (limb-girdle muscular dystrophy), and peroneal muscu-
lar atrophy with any degree of AV block (including first-degree AV
block), with or without symptoms, because there may be unpre-
dictable progression of AV conduction disease. (Level of Evi-
dence: B) (28–34)
2. Permanent pacemaker implantation may be considered for 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.
(Level of Evidence: B) (43,44)
CLASS III
1. Permanent pacemaker implantation is not indicated for asymp-
tomatic first-degree AV block. (Level of Evidence: B) (45) (See
Section 2.1.3, “Chronic Bifascicular Block,” in the full-text
guidelines.)
2. Permanent pacemaker implantation is not indicated for asymp-
tomatic type I second-degree AV block at the supra-His (AV
node) level or that which is not known to be intra- or infra-Hisian.
(Level of Evidence: C) (35)
3. Permanent pacemaker implantation is not indicated for
AV block that is expected to resolve and is unlikely to recur
(46) (e.g., drug toxicity, Lyme disease, or transient in-
creases in vagal tone, or during hypoxia in sleep apnea
syndrome in the absence of symptoms). (Level of Evidence: B)
(44,46)
Figure 2. Selection of Pacemaker Systems for Patients With Atrioventricular Block
Decisions are illustrated by diamonds. Shaded boxes indicate type of pacemaker. AV indicates atrioventricular.
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4. Recommendations for Permanent Pacing
in Chronic Bifascicular Block
CLASS I
1. Permanent pacemaker implantation is indicated for advanced
second-degree AV block or intermittent third-degree AV block.
(Level of Evidence: B) (19,39,47–51)
2. Permanent pacemaker implantation is indicated for type II
second-degree AV block. (Level of Evidence: B) (52–55)
3. Permanent pacemaker implantation is indicated for alternating
bundle-branch block. (Level of Evidence: C) (56)
CLASS IIa
1. Permanent pacemaker implantation is reasonable for syncope
not demonstrated to be due to AV block when other likely causes
have been excluded, specifically ventricular tachycardia (VT).
(Level of Evidence: B) (55,57–74)
2. Permanent pacemaker implantation is reasonable for an inciden-
tal finding at electrophysiological study of a markedly prolonged
HV interval (greater than or equal to 100 milliseconds) in
asymptomatic patients. (Level of Evidence: B) (65)
3. Permanent pacemaker implantation is reasonable for an inciden-
tal finding at electrophysiological study of pacing-induced infra-
His block that is not physiological. (Level of Evidence: B) (72)
CLASS IIb
1. Permanent pacemaker implantation may be considered in the
setting of neuromuscular diseases such as myotonic muscular
dystrophy, Erb dystrophy (limb-girdle muscular dystrophy), and
peroneal muscular atrophy with bifascicular block or any fascic-
ular block, with or without symptoms. (Level of Evidence: C)
(28–34)
CLASS III
1. Permanent pacemaker implantation is not indicated for fascicu-
lar block without AV block or symptoms. (Level of Evidence: B)
(59,61,64,65)
2. Permanent pacemaker implantation is not indicated for fascicu-
lar block with first-degree AV block without symptoms. (Level of
Evidence: B) (59,61,64,65)
5. Recommendations for Permanent
Pacing After the Acute Phase of
Myocardial Infarction*
CLASS I
1. Permanent ventricular pacing is indicated for persistent second-
degree AV block in the His-Purkinje system with alternating
bundle-branch block or third-degree AV block within or below the
His-Purkinje system after ST-segment elevation myocardial in-
farction. (Level of Evidence: B) (54,75–79)
2. Permanent ventricular pacing is indicated for transient advanced
second- or third-degree infranodal AV block and associated
bundle-branch block. If the site of block is uncertain, an electro-
physiological study may be necessary. (Level of Evidence: B)
(75,76)
3. Permanent ventricular pacing is indicated for persistent and
symptomatic second- or third-degree AV block. (Level of Evi-
dence: C)
CLASS IIb
1. Permanent ventricular pacing may be considered for persistent
second- or third-degree AV block at the AV node level, even in the
absence of symptoms. (Level of Evidence: B) (14)
CLASS III
1. Permanent ventricular pacing is not indicated for transient AV
block in the absence of intraventricular conduction defects.
(Level of Evidence: B) (75)
2. Permanent ventricular pacing is not indicated for transient AV
block in the presence of isolated left anterior fascicular block.
(Level of Evidence: B) (77)
3. Permanent ventricular pacing is not indicated for new bundle-
branch block or fascicular block in the absence of AV block.
(Level of Evidence: B) (48,75)
4. Permanent ventricular pacing is not indicated for persistent
asymptomatic first-degree AV block in the presence of bundle-
branch or fascicular block. (Level of Evidence: B) (75)
6. Recommendations for Permanent Pacing
in Hypersensitive Carotid Sinus Syndrome
and Neurocardiogenic Syncope
CLASS I
1. Permanent pacing is indicated for recurrent syncope caused by
spontaneously occurring carotid sinus stimulation and carotid
sinus pressure that induces ventricular asystole of more than 3
seconds. (Level of Evidence: C) (80,81)
CLASS IIa
1. Permanent pacing is reasonable for syncope without clear,
provocative events and with a hypersensitive cardioinhibitory
response of 3 seconds or longer. (Level of Evidence: C) (80)
CLASS IIb
1. Permanent pacing may be considered for significantly symptom-
atic neurocardiogenic syncope associated with bradycardia doc-
umented spontaneously or at the time of tilt-table testing. (Level
of Evidence: B) (82–85)
CLASS III
1. Permanent pacing is not indicated for a hypersensitive cardioin-
hibitory response to carotid sinus stimulation without symptoms
or with vague symptoms. (Level of Evidence: C)
2. Permanent pacing is not indicated for situational vasovagal
syncope in which avoidance behavior is effective and preferred.
(Level of Evidence: C)
7. Recommendations for Pacing After
Cardiac Transplantation
CLASS I
1. Permanent pacing is indicated for persistent inappropriate or
symptomatic bradycardia not expected to resolve and for
other Class I indications for permanent pacing. (Level of
Evidence: C)
*These recommendations are consistent with the “ACC/AHA Guidelines for the
Management of Patients With ST-Elevation Myocardial Infarction” (8).
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CLASS IIb
1. Permanent pacing may be considered when relative bradycardia
is prolonged or recurrent, which limits rehabilitation or discharge
after postoperative recovery from cardiac transplantation. (Level
of Evidence: C)
2. Permanent pacing may be considered for syncope after cardiac
transplantation even when bradyarrhythmia has not been docu-
mented. (Level of Evidence: C)
8. Recommendations for Permanent
Pacemakers That Automatically Detect and
Pace to Terminate Tachycardias
CLASS IIa
1. Permanent pacing is reasonable for symptomatic recurrent su-
praventricular tachycardia that is reproducibly terminated by
pacing when catheter ablation and/or drugs fail to control the
arrhythmia or produce intolerable side effects. (Level of Evi-
dence: C) (86–90)
CLASS III
1. Permanent pacing is not indicated in the presence of an acces-
sory pathway that has the capacity for rapid anterograde con-
duction. (Level of Evidence: C)
9. Recommendations for Pacing to
Prevent Tachycardia
CLASS I
1. Permanent pacing is indicated for sustained pause-dependent
VT, with or without QT prolongation. (Level of Evidence: C)
(91,92)
CLASS IIa
1. Permanent pacing is reasonable for high-risk patients with con-
genital long-QT syndrome. (Level of Evidence: C) (91,92)
CLASS IIb
1. Permanent pacing may be considered for prevention of symptom-
atic, drug-refractory, recurrent atrial fibrillation in patients with
coexisting SND. (Level of Evidence: B) (93–95)
CLASS III
1. Permanent pacing is not indicated for frequent or complex
ventricular ectopic activity without sustained VT in the absence
of the long-QT syndrome. (Level of Evidence: C) (97)
2. Permanent pacing is not indicated for torsade de pointes VT due
to reversible causes. (Level of Evidence: A) (98,99)
10. Recommendation for Pacing to Prevent
Atrial Fibrillation
CLASS III
1. Permanent pacing is not indicated for the prevention of atrial
fibrillation in patients without any other indication for pacemaker
implantation. (Level of Evidence: B) (100)
11. Recommendations for Cardiac
Resynchronization Therapy in Patients With
Severe Systolic Heart Failure
CLASS I
1. For patients who have LV ejection fraction (LVEF) less than or
equal to 35%, a QRS duration greater than or equal to 0.12
seconds, and sinus rhythm, CRT with or without an ICD is
indicated for the treatment of New York Heart Association
(NYHA) functional Class III or ambulatory Class IV heart failure
symptoms with optimal recommended medical therapy. (Level of
Evidence: A) (101,101a–101c)
CLASS IIa
1. For patients who have LVEF less than or equal to 35%, a QRS
duration greater than or equal to 0.12 seconds, and atrial
fibrillation, CRT with or without an ICD is reasonable for the
treatment of NYHA functional Class III or ambulatory Class IV
heart failure symptoms on optimal recommended medical ther-
apy. (Level of Evidence: B) (101,102)
2. For patients with LVEF less than or equal to 35% with NYHA
functional Class III or ambulatory Class IV symptoms who are
receiving optimal recommended medical therapy and who have
frequent dependence on ventricular pacing, CRT is reasonable.
(Level of Evidence: C) (101)
CLASS IIb
1. For patients with LVEF less than or equal to 35% with NYHA
functional Class I or II symptoms who are receiving optimal
recommended medical therapy undergoing implantation of a
permanent pacemaker and/or ICD with anticipated frequent
ventricular pacing, CRT may be considered. (Level of Evidence:
C) (101)
CLASS III
1. CRT is not indicated for asymptomatic patients with reduced
LVEF in the absence of other indications for pacing. (Level of
Evidence: B) (101,101a–101c)
2. CRT is not indicated for patients whose functional status and life
expectancy are limited predominantly by chronic noncardiac
conditions. (Level of Evidence: C) (101)
12. Recommendations for Pacing in Patients
With Hypertrophic Cardiomyopathy
CLASS I
1. Permanent pacing is indicated for SND or AV block in patients
with hypertrophic cardiomyopathy as described previously (see
Section 2.1.1, “Sinus Node Dysfunction,” and Section 2.1.2,
“Acquired Atrioventricular Block in Adults,” in the full-text guide-
lines). (Level of Evidence: C)
CLASS IIb
1. Permanent pacing may be considered in medically refractory
symptomatic patients with hypertrophic cardiomyopathy and
significant resting or provoked LV outflow tract obstruction.
(Level of Evidence: A) As for Class I indications, when risk
factors for SCD are present, consider a DDD ICD (see Section 3,
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“Indications for Implantable Cardioverter-Defibrillator Therapy,”
in the full-text guidelines). (103–108)
CLASS III
1. Permanent pacemaker implantation is not indicated for patients
who are asymptomatic or whose symptoms are medically con-
trolled. (Level of Evidence: C)
2. Permanent pacemaker implantation is not indicated for symp-
tomatic patients without evidence of LV outflow tract obstruc-
tion. (Level of Evidence: C)
13. Recommendations for Permanent Pacing
in Children, Adolescents, and Patients With
Congenital Heart Disease
CLASS I
1. Permanent pacemaker implantation is indicated for advanced
second- or third-degree AV block associated with symptomatic
bradycardia, ventricular dysfunction, or low cardiac output.
(Level of Evidence: C)
2. Permanent pacemaker implantation is indicated for SND 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) (9,22,109,110)
3. Permanent pacemaker implantation is indicated for postopera-
tive advanced second- or third-degree AV block that is not
expected to resolve or that persists at least 7 days after cardiac
surgery. (Level of Evidence: B) (35,111)
4. Permanent pacemaker implantation is indicated for congenital
third-degree AV block with a wide QRS escape rhythm, complex
ventricular ectopy, or ventricular dysfunction. (Level of Evidence:
B) (113–115)
5. Permanent pacemaker implantation is indicated for congenital
third-degree AV block in the infant with a ventricular rate less
than 55 bpm or with congenital heart disease and a ventricular
rate less than 70 bpm. (Level of Evidence: C) (116,117)
CLASS IIa
1. Permanent pacemaker implantation is reasonable for patients
with congenital heart disease and sinus bradycardia for the
prevention of recurrent episodes of intra-atrial re-entrant tachy-
cardia; SND may be intrinsic or secondary to antiarrhythmic
treatment. (Level of Evidence: C) (118–120)
2. Permanent pacemaker implantation is reasonable for 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 2 or 3 times the basic cycle length, or associated with
symptoms due to chronotropic incompetence. (Level of Evi-
dence: B) (121,122)
3. Permanent pacemaker implantation is reasonable for sinus bra-
dycardia with complex congenital heart disease with a resting
heart rate less than 40 bpm or pauses in ventricular rate longer
than 3 seconds. (Level of Evidence: C)
4. Permanent pacemaker implantation is reasonable for patients with
congenital heart disease and impaired hemodynamics due to sinus
bradycardia or loss of AV synchrony. (Level of Evidence: C) (123)
5. Permanent pacemaker implantation is reasonable for unex-
plained syncope in the patient with prior congenital heart surgery
complicated by transient complete heart block with residual
fascicular block after a careful evaluation to exclude other
causes of syncope. (Level of Evidence: B) (115,124–126)
CLASS IIb
1. Permanent pacemaker implantation may be considered for tran-
sient postoperative third-degree AV block that reverts to sinus
rhythm with residual bifascicular block. (Level of Evidence: C) (127)
2. Permanent pacemaker implantation may be considered for con-
genital third-degree AV block in asymptomatic children or ado-
lescents with an acceptable rate, a narrow QRS complex, and
normal ventricular function. (Level of Evidence: B) (113,122)
3. Permanent pacemaker implantation may be considered for
asymptomatic sinus bradycardia after biventricular repair of
congenital heart disease with a resting heart rate less than 40
bpm or pauses in ventricular rate longer than 3 seconds. (Level
of Evidence: C)
CLASS III
1. Permanent pacemaker implantation is not indicated for transient
postoperative AV block with return of normal AV conduction in
the otherwise asymptomatic patient. (Level of Evidence: B)
(127,127a)
2. Permanent pacemaker implantation is not indicated for asymp-
tomatic bifascicular block with or without first-degree AV block
after surgery for congenital heart disease in the absence of prior
transient complete AV block. (Level of Evidence: C)
3. Permanent pacemaker implantation is not indicated for asymp-
tomatic type I second-degree AV block. (Level of Evidence: C)
4. Permanent pacemaker implantation is not indicated for asymp-
tomatic sinus bradycardia with the longest relative risk interval
less than 3 seconds and a minimum heart rate more than 40
bpm. (Level of Evidence: C)
14. Recommendations for Implantable
Cardioverter-Defibrillators
Secondary prevention refers to the prevention of SCD in
those patients who have survived a prior cardiac arrest or
sustained VT. Primary prevention refers to the prevention
of SCD in individuals without a history of cardiac arrest or
sustained VT. Patients with cardiac conditions associated
with a high risk of sudden death who have unexplained
syncope that is likely to be due to ventricular arrhythmias are
considered to have a secondary indication.
Recommendations for consideration of ICD therapy,
particularly those for primary prevention, apply only to
patients who are receiving optimal medical therapy and have
a reasonable expectation of survival with good functional
status for more than 1 year. It is difficult to estimate survival
with heart failure in the general population, for whom
comorbidities and age differ from those in trial populations
from which the predictive models have been derived. Pa-
tients with repeated heart failure hospitalizations, particu-
larly in the presence of reduced renal function, are at high
risk for early death due to heart failure (128–130). Please
see Section 3, “Indications for Implantable Cardioverter-
Defibrillator Therapy,” in the full-text guidelines for dis-
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ACC/AHA/HRS Guidelines for Device-Based Therapy: Executive Summary
cussion regarding the use of LVEFs on the basis of trial
inclusion criteria.
We acknowledge that the “ACC/AHA/ESC 2006
Guidelines for Management of Patients With Ventricular
Arrhythmias and the Prevention of Sudden Cardiac Death”
(4) used an LVEF of less than 40% as a critical point to
justify ICD implantation for primary prevention of SCD.
The LVEF used in clinical trials assessing the ICD for
primary prevention of SCD ranged from less than 40% in
MUSTT (Multicenter Unsustained Ventricular Tachycar-
dia Trial) to less than 30% in MADIT II (Multicenter
Automatic Defibrillator Implantation Trial II) (131,132).
Two trials, MADIT I (Multicenter Automatic Defibrillator
Implantation Trial I) (6) and SCD-HeFT (Sudden Cardiac
Death in Heart Failure Trial) (7) used LVEFs of less than
35% as entry criteria. The present writing committee
reached the consensus that it would be best to offer ICDs to
patients with clinical profiles as similar to those included in
the trials as possible. Having given careful consideration to
the issues related to LVEF for these updated ICD guide-
lines, we have written these indications for ICDs on the
basis of the specific inclusion criteria for LVEF in the trials.
Because of this, there may be some variation from previously
published guidelines (4).
We also acknowledge that the determination of LVEF
lacks a “gold standard” and that there may be variation
among the commonly used clinical techniques of LVEF
determination. All clinical methods of LVEF determination
lack precision, and the accuracy of techniques varies among
laboratories and institutions. On the basis of these consid-
erations, the present writing committee recommends that
clinicians use the LVEF determination that they believe
is the most clinically accurate and appropriate in their
institution.
CLASS I
1. ICD therapy is indicated in patients who are survivors of cardiac
arrest due to ventricular fibrillation or hemodynamically unstable
sustained VT after evaluation to define the cause of the event
and to exclude any completely reversible causes. (Level of
Evidence: A) (4,133–138)
2. ICD therapy is indicated in patients with structural heart disease
and spontaneous sustained VT, whether hemodynamically stable
or unstable. (Level of Evidence: B) (4,133–138)
3. ICD therapy is indicated in patients with syncope of undeter-
mined origin with clinically relevant, hemodynamically signifi-
cant sustained VT or ventricular fibrillation induced at electro-
physiological study. (Level of Evidence: B) (4,136)
4. ICD therapy is indicated in patients with LVEF less than 35% due
to prior myocardial infarction who are at least 40 days post--
myocardial infarction and are in NYHA functional Class II or III.
(Level of Evidence: A) (4,139)
5. ICD therapy is indicated in patients with nonischemic dilated
cardiomyopathy who have an LVEF less than or equal to 35% and
who are in NYHA functional Class II or III. (Level of Evidence: B)
(4,139–141)
6. ICD therapy is indicated in patients with LV dysfunction due to
prior myocardial infarction who are at least 40 days post--
myocardial infarction, have an LVEF less than 30%, and are in
NYHA functional Class I. (Level of Evidence: A) (4,132)
7. ICD therapy is indicated in patients with nonsustained VT due to
prior myocardial infarction, LVEF less than 40%, and inducible
ventricular fibrillation or sustained VT at electrophysiological
study. (Level of Evidence: B) (4,131,142)
CLASS IIa
1. ICD implantation is reasonable for patients with unexplained
syncope, significant LV dysfunction, and nonischemic dilated
cardiomyopathy. (Level of Evidence: C)
2. ICD implantation is reasonable for patients with sustained VT
and normal or near-normal ventricular function. (Level of Evi-
dence: C)
3. ICD implantation is reasonable for patients with hypertrophic
cardiomyopathy who have 1 or more major risk factor for SCD.
(Level of Evidence: C)
4. ICD implantation is reasonable for the prevention of SCD in
patients with arrhythmogenic right ventricular dysplasia/cardio-
myopathy who have 1 or more risk factor for SCD. (Level of
Evidence: C)
5. ICD implantation is reasonable to reduce SCD in patients with
long-QT syndrome who are experiencing syncope and/or VT while
receiving beta blockers. (Level of Evidence: B) (143–148)
6. ICD implantation is reasonable for nonhospitalized patients
awaiting transplantation. (Level of Evidence: C)
7. ICD implantation is reasonable for patients with Brugada syn-
drome who have had syncope. (Level of Evidence: C)
8. ICD implantation is reasonable for patients with Brugada syn-
drome who have documented VT that has not resulted in cardiac
arrest. (Level of Evidence: C)
9. ICD implantation is reasonable for patients with catecholamin-
ergic polymorphic VT who have syncope and/or documented sus-
tained VT while receiving beta blockers. (Level of Evidence: C)
10. ICD implantation is reasonable for patients with cardiac sar-
coidosis, giant cell myocarditis, or Chagas disease. (Level of
Evidence: C)
CLASS IIb
1. ICD therapy may be considered in patients with nonischemic
heart disease who have an LVEF of less than or equal to 35% and
who are in NYHA functional Class I. (Level of Evidence: C)
2. ICD therapy may be considered for patients with long-QT syndrome
and risk factors for SCD. (Level of Evidence: B) (4,143–148)
3. ICD therapy may be considered in patients with syncope and
advanced structural heart disease in whom thorough invasive
and noninvasive investigations have failed to define a cause.
(Level of Evidence: C)
4. ICD therapy may be considered in patients with a familial
cardiomyopathy associated with sudden death. (Level of Evi-
dence: C)
5. ICD therapy may be considered in patients with LV noncompac-
tion. (Level of Evidence: C)
CLASS III
1. ICD therapy is not indicated for patients who do not have a
reasonable expectation of survival with an acceptable functional
status for at least 1 year, even if they meet ICD implantation
†See Section 3.2.4, “Hypertrophic Cardiomyopathy,” in the full-text guidelines for
definition of major risk factors.
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criteria specified in the Class I, IIa, and IIb recommendations
above. (Level of Evidence: C)
2. ICD therapy is not indicated for patients with incessant VT or
ventricular fibrillation. (Level of Evidence: C)
3. ICD therapy is not indicated in patients with significant psychi-
atric illnesses that may be aggravated by device implantation or
that may preclude systematic follow-up. (Level of Evidence: C)
4. ICD therapy is not indicated for NYHA Class IV patients with drug-
refractory congestive heart failure who are not candidates for cardiac
transplantation or implantation of a CRT device that incorporates both
pacing and defibrillation capabilities. (Level of Evidence: C)
5. ICD therapy is not indicated for syncope of undetermined cause
in a patient without inducible ventricular tachyarrhythmias and
without structural heart disease. (Level of Evidence: C)
6. ICD therapy is not indicated when ventricular fibrillation or VT is
amenable to surgical or catheter ablation (e.g., atrial arrhythmias
associated with Wolff-Parkinson-White syndrome, right ventricular
or LV outflow tract VT, idiopathic VT, or fascicular VT in the absence
of structural heart disease). (Level of Evidence: C)
7. ICD therapy is not indicated for patients with ventricular tachy-
arrhythmias due to a completely reversible disorder in the
absence of structural heart disease (e.g., electrolyte imbalance,
drugs, or trauma). (Level of Evidence: B) (4)
15. Recommendations for Implantable
Cardioverter-Defibrillators in Pediatric
Patients and Patients With Congenital
Heart Disease
CLASS I
1. ICD implantation is indicated in the survivor of cardiac arrest
after evaluation to define the cause of the event and to exclude
any reversible causes. (Level of Evidence: B) (149–152)
2. ICD implantation is indicated for patients with symptomatic
sustained VT in association with congenital heart disease who
have undergone hemodynamic and electrophysiological evalua-
tion. Catheter ablation or surgical repair may offer possible
alternatives in carefully selected patients. (Level of Evidence: C)
(153)
CLASS IIa
1. ICD implantation is reasonable for patients with congenital heart
disease with recurrent syncope of undetermined origin in the
presence of either ventricular dysfunction or inducible ventricular
arrhythmias at electrophysiological study. (Level of Evidence: B)
(6,154)
CLASS Ib
1. ICD implantation may be considered for patients with recurrent
syncope associated with complex congenital heart disease and
advanced systemic ventricular dysfunction when thorough inva-
sive and noninvasive investigations have failed to define a cause.
(Level of Evidence: C) (155,156)
CLASS III
1. All Class III recommendations found in Section 3 of the full-text
guidelines, “Indications for Implantable Cardioverter-Defibrillator
Therapy,” apply to pediatric patients or patients with congenital
heart disease, and ICD implantation is not indicated in these
patient populations. (Level of Evidence: C)
Staff
American College of Cardiology Foundation
John C. Lewin, MD, Chief Executive Officer
Charlene May, Senior Director, Clinical Policy and
Guidelines
Lisa Bradfield, Associate Director, Practice Guidelines
Mark D. Stewart, MPH, Associate Director, Evidence-
Based Medicine
Kristen N. Fobbs, MS, Senior Specialist, Practice Guidelines
Erin A. Barrett, Senior Specialist, Clinical Policy and
Guidelines
American Heart Association
M. Cass Wheeler, Chief Executive Officer
Gayle R. Whitman, RN, PhD, FAAN, FAHA, Vice
President, Office of Science Operations
Kathryn A. Taubert, PhD, FAHA, Senior Science Advisor
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141. Desai AS, Fang JC, Maisel WH, Baughman KL. Implantable
defibrillators for the prevention of mortality in patients with non-
ischemic cardiomyopathy: a meta-analysis of randomized controlled
trials. JAMA. 2004;292:2874 –9.
142. Moss AJ, Hall WJ, Cannom DS, et al. Improved survival with an
implanted defibrillator in patients with coronary disease at high risk
for ventricular arrhythmia. Multicenter Automatic Defibrillator Im-
plantation Trial Investigators. N Engl J Med. 1996;335:1933–40.
143. Zareba W, Moss AJ, Daubert JP, Hall WJ, Robinson JL, Andrews
M. Implantable cardioverter defibrillator in high-risk long QT
syndrome patients. J Cardiovasc Electrophysiol. 2003;14:337–41.
2100 Epstein
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ACC/AHA/HRS Guidelines for Device-Based Therapy: Executive Summary
May 27, 2008:2085–105
144. Viskin S. Implantable cardioverter defibrillator in high-risk long QT
syndrome patients. J Cardiovasc Electrophysiol. 2003;14:1130–1.
145. Goel AK, Berger S, Pelech A, Dhala A. Implantable cardioverter
defibrillator therapy in children with long QT syndrome. Pediatr
Cardiol. 2004;25:370 8.
146. Monnig G, Kobe J, Loher A, et al. Implantable cardioverter-
defibrillator therapy in patients with congenital long-QT syndrome:
a long-term follow-up. Heart Rhythm. 2005;2:497–504.
147. Goldenberg I, Mathew J, Moss AJ, et al. Corrected QT variability in
serial electrocardiograms in long QT syndrome: the importance of
the maximum corrected QT for risk stratification. J Am Coll Cardiol.
2006;48:1047–52.
148. Hobbs JB, Peterson DR, Moss AJ, et al. Risk of aborted cardiac arrest
or sudden cardiac death during adolescence in the long-QT syn-
drome. JAMA. 2006;296:1249 –54.
149. Silka MJ, Kron J, Dunnigan A, Dick M. Sudden cardiac death and
the use of implantable cardioverter-defibrillators in pediatric patients.
The Pediatric Electrophysiology Society. Circulation. 1993;87:
800–7.
150. Hamilton RM, Dorian P, Gow RM, Williams WG. Five-year
experience with implantable defibrillators in children. Am J Cardiol.
1996;77:524 6.
151. Alexander ME, Cecchin F, Walsh EP, Triedman JK, Bevilacqua
LM, Berul CI. Implications of implantable cardioverter defibrillator
therapy in congenital heart disease and pediatrics. J Cardiovasc
Electrophysiol. 2004;15:72–6.
152. Choi GR, Porter CB, Ackerman MJ. Sudden cardiac death and
channelopathies: a review of implantable defibrillator therapy. Pediatr
Clin North Am. 2004;51:1289 –303.
153. Karamlou T, Silber I, Lao R, et al. Outcomes after late reoperation
in patients with repaired tetralogy of Fallot: the impact of arrhythmia
and arrhythmia surgery. Ann Thorac Surg. 2006;81:1786–93.
154. Khairy P, Landzberg MJ, Gatzoulis MA, et al. Value of programmed
ventricular stimulation after tetralogy of Fallot repair: a multicenter
study. Circulation. 2004;109:1994 –2000.
155. Kammeraad JA, van Deurzen CH, Sreeram N, et al. Predictors of
sudden cardiac death after Mustard or Senning repair for transposi-
tion of the great arteries. J Am Coll Cardiol. 2004;44:1095–102.
156. Dubin AM, Berul CI, Bevilacqua LM, et al. The use of implantable
cardioverter-defibrillators in pediatric patients awaiting heart trans-
plantation. J Card Fail. 2003;9:375–9.
Key Words: ACC/AHA practice guideline y device-based therapy y
implantable cardioverter-defibrillator y implantable coronary device y
arrhythmia y pacemaker y pacing y cardiomyopathy.
APPENDIX 1. AUTHOR RELATIONSHIPS WITH INDUSTRY—ACC/AHA/HRS GUIDELINES FOR DEVICE-BASED
THERAPY OF CARDIAC RHYTHM ABNORMALITIES
Committee Member
Consulting Fees/
Honoraria Speakers’ Bureau
Ownership/
Partnership/
Principal Research Grants
Institutional or Other
Financial Benefit
Dr. Andrew E.
Epstein*
Boston Scientific
CryoCath
Medtronic
Sanofi-Aventis
St. Jude†
Boston Scientific
Medtronic
Reliant Pharmaceuticals
Sanofi-Aventis
St. Jude
None
Biotronik†
Boston Scientific†
C. R. Bard/
Electrophysiology Division†
Irving Biomedical†
Medtronic†
St. Jude†
Electrophysiology
fellowship support from:
Medtronic†
St. Jude†
Dr. John P. DiMarco*
Boston Scientific†
CV Therapeutics†
Daiichi Sankyo
Medtronic†
Novartis†
St. Jude
Solvay
Sanofi-Aventis
None None
Boston Scientific†
CV Therapeutics†
Medtronic
Sanofi-Aventis
St. Jude
None
Dr. Kenneth A.
Ellenbogen*
Ablation Frontiers
Atricure
Biosense Webster
Biotronik
Boston Scientific
Medtronic
St. Jude
Sorin/ELA
Reliant Pharmaceuticals
Sanofi-Aventis
None
Biosense Webster
Boston Scientific†
Cameron Medical
Impulse Dynamics
Medtronic†
St. Jude
None
Dr. N.A. Mark
Estes III
Medtronic Boston Scientific
Medtronic
St. Jude
None None None
Dr. Roger A.
Freedman*
Boston Scientific
Medtronic
Sorin/ELA
St. Jude
Boston Scientific
St. Jude
St. Jude Boston Scientific†
Medtronic†
St. Jude†
University of Utah Division
of Cardiology receives
electrophysiology
fellowship support grants
from:
Boston Scientific†
Medtronic†
St. Jude†
2101
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Epstein
et al.
May 27, 2008:2085–105
ACC/AHA/HRS Guidelines for Device-Based Therapy: Executive Summary
Committee Member
Consulting Fees/
Honoraria Speakers’ Bureau
Ownership/
Partnership/
Principal Research Grants
Institutional or Other
Financial Benefit
Dr. Leonard S.
Gettes
None None None None None
Dr. A. Marc Gillinov*
AtriCure
Edwards†
Medtronic
Guidant
St. Jude
Viacor† None None
Dr. Gabriel
Gregoratos
None None None None None
Dr. Stephen C.
Hammill
Biosense Webster Boston Scientific None Medtronic None
Dr. David L. Hayes*
AI Semi
Blackwell/Futura†
Boston Scientific†
Medtronic†
Sorin/ELA
St. Jude
None None
Boston Scientific†
Medtronic†
St. Jude
Biotronik
Boston Scientific†
Medtronic†
Sorin/ELA
St. Jude
Dr. Mark A. Hlatky
Blue Cross/Blue Shield
Technology Evaluation
Center
None None None None
Dr. L. Kristin Newby
AstraZeneca/Atherogenics
Biosite
CV Therapeutics
Johnson & Johnson
Novartis
Procter & Gamble
Roche Diagnostics
None None
Adolor
American Heart
Association†
BG Medicine
Bristol-Myers
Squibb/Sanoޠ
Inverness Medical†
Medicure†
Schering-Plough†
None
Dr. Richard L. Page
Astellas
Berlex
Pfizer
Sanofi-Aventis†
None None
Procter & Gamble Boston Scientific†
Medtronic†
St. Jude†
Dr. Mark H.
Schoenfeld
None None None None None
Dr. Michael J. Silka None None None None None
Dr. Lynne Warner
Stevenson
Biosense Webster‡
Boston Scientific‡
CardioMEMS
Medtronic
Medtronic‡
Scios
None None
Biosense Webster‡
Medtronic
None
Dr. Michael O.
Sweeney*
Medtronic† Boston Scientific
Medtronic†
None None None
This table represents the relationships of committee members with industry that were reported orally at the initial writing committee meeting and updated in conjunction with all meetings and conference
calls of the writing committee during the document development process (last revision, January 16, 2008). It does not necessarily reflect relationships with industry at the time of publication. A person
is deemed to have a significant interest in a business if the interest represents ownership of 5% or more of the voting stock or share of the business entity, or ownership of $10 000 or more of the
fair market value of the business entity, or if funds received by the person from the business entity exceed 5% of the person’s gross income for the previous year. A relationship is considered to be
modest if it is less than significant under the preceding definition. Relationships noted in this table are modest unless otherwise noted.
*Recused from voting on guideline recommendations. Indicates significant-level relationship (more than $10 000). Indicates spousal relationship.
2102 Epstein
et al.
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ACC/AHA/HRS Guidelines for Device-Based Therapy: Executive Summary
May 27, 2008:2085–105
APPENDIX 2. PEER REVIEWER RELATIONSHIPS WITH INDUSTRY—ACC/AHA/HRS GUIDELINES FOR
DEVICE-BASED THERAPY OF CARDIAC RHYTHM ABNORMALITIES
Peer Reviewer* Representation
Consulting Fees/
Honoraria Speakers’ Bureau
Ownership/
Partnership/
Principal Research Grant
Institutional or
Other Financial
Benefit
Dr. Mina K. Chung Official—Heart Rhythm
Society
American College
of Cardiology
Foundation
Boston Medical
Center
Boston Scientific
(honoraria
donated)
Elsevier
Medtronic
(honoraria
donated)
Nexcura (no
honoraria
received)
University of Texas
Health Science
Center
WebMD Health
(For CryoCath
Technologies, Inc.)
None None
Biotronik† (research
grants to
electrophysiology
section, Cleveland
Clinic)
Boston Scientific†
(research grants to
electrophysiology
section, Cleveland
Clinic)
Medtronic* (research
grants to
electrophysiology
section, Cleveland
Clinic)
Reliant
Pharmaceuticals†
(research grants to
electrophysiology
section, Cleveland
Clinic)
St. Jude Medical†
(research grants to
electrophysiology
section, Cleveland
Clinic)
None
Dr. Fred Kusumoto Official—Heart Rhythm
Society
Boston Scientific
Medtronic
None None None None
Dr. Bruce Lindsay Official—American
College of Cardiology
Board of Trustees
None None None None None
Dr. Samir Saba Official—American Heart
Association
None None None
Boston Scientific
Medtronic
St. Jude Medical
None
Dr. Paul Wang Official—American Heart
Association;
Content—American Heart
Association
Electrocardiography and
Arrhythmias Committee
Boston Scientific†
Lifewatch†
Medtronic
St. Jude
Boston Scientific†
Medtronic
St. Jude
Hansen
Medical†
Boston Scientific†
Medtronic
St. Jude
None
Dr. Stuart Winston Official—American
College of Cardiology
Board of Governors
Boston Scientific None None None None
Dr. Patrick McCarthy Organizational—Society of
Thoracic Surgeons
CV Therapeutics†
Medtronic
None None None None
Dr. Mandeep Mehra Organizational—Heart
Failure Society of
America
Astellas
Boston Scientific
Cordis
Debiopharma
Medtronic
Novartis
Roche Diagnostics
Scios
Solvay
St. Jude
None None
National Institutes of
Health†
Maryland Industrial
Partnerships†
Other Tobacco
Related Diseases†
University of
Maryland†
(salary);
Legal
consultant
2103
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et al.
May 27, 2008:2085–105
ACC/AHA/HRS Guidelines for Device-Based Therapy: Executive Summary
Peer Reviewer* Representation
Consulting Fees/
Honoraria Speakers’ Bureau
Ownership/
Partnership/
Principal Research Grant
Institutional or
Other Financial
Benefit
Dr. Jennifer
Cummings
Content—American
College of Cardiology
Foundation Clinical
Electrophysiology
Committee
Corazon
Medtronic
Reliant
Signalife
St. Jude
Zin
None None None None
Dr. Christopher
Fellows
Content—American
College of Cardiology
Foundation Clinical
Electrophysiology
Committee
Boston Scientific
St. Jude
None None None None
Dr. Nora
Goldschlager
Content—Individual
St. Jude None None None None
Dr. Peter Kowey Content—American
College of Cardiology
Foundation Clinical
Electrophysiology
Committee
None
Medtronic† CardioNet† None None
Dr. Rachel Lampert Content—Heart Rhythm
Society Scientific and
Clinical Documents
Committee
None None None
Boston Scientific†
Medtronic†
St. Jude†
None
Dr. J. Philip Saul Content—Pediatric Expert
and American College
of Cardiology
Foundation Clinical
Electrophysiology
Committee
None None None None None
Dr. George Van Hare Content—Individual
St. Jude None None Medtronic†
(fellowship funding)
None
Dr. Edward P. Walsh Content—Individual
Pediatric Expert
None None None None None
Dr. Clyde Yancy Content—American
College of Cardiology/
American Heart
Association Lead Task
Force Reviewer and
2005 Chronic Heart
Failure Guideline
Writing Committee
AstraZeneca
GlaxoSmithKline
Medtronic
NitroMed
Otsuka
Scios
GlaxoSmithKline
Novartis
None
GlaxoSmithKline
Medtronic
NitroMed
Scios
None
This table represents the relationships of reviewers with industry that were reported at peer review. It does not necessarily reflect relationships with industry at the time of publication. A person is deemed
to have a significant interest in a business if the interest represents ownership of 5% or more of the voting stock or share of the business entity, or ownership of $10 000 or more of the fair market
value of the business entity, or if funds received by the person from the business entity exceed 5% of the person’s gross income for the previous year. A relationship is considered to be modest if it
is less than significant under the preceding definition. Relationships noted in this table are modest unless otherwise noted.
*Names are listed in alphabetical order within each category of review. Participation in the peer review process does not imply endorsement of this document. Indicates significant-level relationship
(more than $10 000).
2104 Epstein
et al.
JACC Vol. 51, No. 21, 2008
ACC/AHA/HRS Guidelines for Device-Based Therapy: Executive Summary
May 27, 2008:2085–105
APPENDIX 3. ABBREVIATIONS LIST
ACC American College of Cardiology
ACCF American College of Cardiology Foundation
AHA American Heart Association
AV Atrioventricular
CRT Cardiac resynchronization therapy
DDD Dual-chamber pacemaker that senses/paces in the atrium/ventricle and is inhibited/triggered by intrinsic rhythm
LVEF Left ventricular ejection fraction
HRS Heart Rhythm Society
ICD Implantable cardioverter-defibrillator
LV Left ventricular/left ventricle
MADIT I Multicenter Automatic Defibrillator Implantation Trial I
MADIT II Multicenter Automatic Defibrillator Implantation Trial II
MUSTT Multicenter UnSustained Ventricular Tachycardia Trial
NYHA New York Heart Association
SCD Sudden cardiac death
SCD-HeFT Sudden Cardiac Death in Heart Failure Trial
SND Sinus node dysfunction
VT Ventricular tachycardia
2105
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ACC/AHA/HRS Guidelines for Device-Based Therapy: Executive Summary
    • "In our case, there was no clinical or laboratory evidence of maternal or fetal autoimmune disease. The 2008 guidelines of the American Heart Association, the American College of Cardiology Foundation, and the Heart Rhythm Society recommend that a permanent pacemaker be implanted in patients with congenital complete AV block with no delay (15). However, there are several problems with doing this in neonates and young infants. "
    [Show abstract] [Hide abstract] ABSTRACT: Congenital myotonic dystrophy (CMD) is an inherited neuromuscular disorder with cardiac rhythm abnormalities that may occur as a child grows. No report has described complete atrioventricular (AV) block detected in a neonate with CMD. We report a floppy infant of 31+4 weeks gestation with complete AV block at birth, who was diagnosed with CMD by Southern analysis. She recovered from complete AV block 32 hr after temporary transcutaneous pacing was applied. To the best our knowledge, this is the first recorded case of a complete AV block accompanied by CMD during the neonatal period. When a newborn has a complete AV block, the physician should consider the possibility of the CMD and conduct a careful physical examination. Graphical Abstract
    Full-text · Article · Jun 2014
    • "To our knowledge, no data is available regarding mortality in patients on RRT with permanent pacemakers (PM) [10– 12]. These groups of patients are not included in the current guidelines [13] [14]. Mortality rates are likely to be higher due to the advanced age, the high incidence of stroke, and comorbidities. "
    [Show abstract] [Hide abstract] ABSTRACT: End stage renal disease is a relatively frequent disease with high mortality due to cardiac causes. Permanent pacemaker (PM) implantation rates are also very common; thus combination of both conditions is not unusual. We hypothesized that patients with chronic kidney disease with a PM would have significantly higher mortality rates compared with end stage renal disease patients without PM. Our objectives were to analyze mortality of patients on renal replacement therapy with PM. 2778 patients were on renal replacement therapy (RRT) and 110 had a PM implanted during the study period. To reduce the confounding effects of covariates, a propensity-matched score was performed. 52 PM patients and 208 non-PM matched patients were compared. 41% of the PM were implanted before entering the RRT program and 59% while on RRT. Mortality was higher in the PM group. Cardiovascular disease and infections were the most frequent causes of death. Propensity analysis showed no differences in long-term mortality between groups. We concluded that in patients on RRT and PM mortality rates are higher. Survival curves did not differ from a RRT propensity-matched group. We concluded that the presence of a PM is not an independent mortality risk factor in RRT patients.
    Full-text · Article · May 2014
    • "This could be explained by the preferential epicardial infiltration of the disease. Indications of ICD for primary prevention of SCD in ARVC/D patients have not been well established [3] [7] "
    Full-text · Article · Apr 2014
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