New ACCF/HRS Statement Provides Expert Guidance on Pacemaker Device and Mode Selection

The ACC Foundation (ACCF) and the Heart Rhythm Society (HRS) on July 30 released a state-of-the-art expert consensus statement focused on pacemaker device and mode selection, specifically in adult patients with sinus node dysfunction (SND), atrioventricular (AV) conduction block and other less common indications for pacing.

Overall, the statement recommends that patients with SND may benefit from atrial or dual-chamber pacing compared with ventricular pacing in terms of reduced risk of atrial fibrillation (AF), stroke, pacemaker syndrome and improved quality of life. It also suggests that over the long term, dual-chamber pacing may be cost-effective – although at this time costs should not be a dominant factor in determining device and/or mode selection. In patients with AV block, the panel notes that dual-chamber pacing can reduce the incidence of pacemaker syndrome and improve some indexes of quality of life compared to ventricular pacing.


The statement also recommends that dual-chamber pacing or single-chamber atrial pacing not be used in patients in permanent or longstanding persistent AF. The authors also note that large, randomized clinical trials addressing unique, less common indications for pacing are unlikely. To that end, they suggest consideration of dual-chamber pacing over single-chamber pacing, despite more frequent implant complications. "The higher risk of complications for dual-chamber pacemakers is offset over time by the need to reoperate on a number of patients with single-chamber pacemakers for AV block or pacemaker syndrome," the statement says.

Approximately 400,000 devices are implanted each year in the U.S, and there are currently more than three million patients with implanted cardiac devices. Over the past 15 years, multiple randomized trials have compared a number of cardiovascular outcomes among patients randomized to atrial or dual-chamber pacing versus those randomized to ventricular pacing, showing an unmet need for uniformed recommendations. The new statement takes into account this new research and expands upon guidelines for device-based therapy of cardiac rhythm abnormalities released by the ACCF, American Heart Association and HRS in 2008. The statement is intended to serve as a framework to assist health care providers in clinical decision-making.

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